Client Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Email *

Would you like to receive email reminders, newsletters or notifications? *

Yes
No

Place of Employment

Work Phone

Co-Owner/Co-Agent Name

Co-Owner/Co-Agent Phone

Emergency Contact Name *

Emergency Contact Phone *

How were you referred to our hospital? (Check all that apply) *

Whom may we thank?

If Other, please explain.

Previous Clinic Information

May we contact your previous veterinarian for copies of medical records? *

Yes
No

If not please upload a copy.

Medical Records Upload

Click or drag files to this area to upload. You can upload up to 5 files.

Clinic/Veterinarian

Location

Previous Clinic Phone

Pet Information

Pet's Name *

Species

Breed

Sex

Male
Female

Spayed/Neutered?

Yes
No
Not Sure

Color

Age/DOB

Pet Insurance*

If your pet is covered under a veterinary insurance policy, please list the company name and policy number:

Insurance Co

Policy No.

*If your pet is not covered by pet insurance, please note that we here at Bristol County Veterinary Hospital highly recommend it. Please ask us about the different plans out there and what we consider to be the top three.

Media Release

After an explanation of its intended use, I authorize the staff at Bristol County Veterinary Hospital to release pictures and videos of my pet and pet's care to use with the following media entities: *

Bristol County Veterinary Hospital Social Media Accounts (Facebook, Instagram)
Bristol County Veterinary Hospital Website
Veterinary Information Network, Journal of AVMA, Other Veterinary Journals
Decline All

I am interested in educating the public about my pet, my pet's condition and medical care and authorize this veterinary practice to use such materials for this purpose. I agree not to file any claim for revenue or lawsuit for damages against this veterinary practice with respect to the release of this information. *

I have read and agree to the terms
I have read and decline

* All fees are due at the time services are rendered * We accept Visa, MasterCard, Discover, and Care Credit credit cards as well as cash and personal checks with proper identification. *

I have read and understand.

I certify that I am the owner, responsible agent for, or authorized agent of this animal. Decisions regarding the care of my pet shall be made only by me or the coowner/co-agent listed above. Information regarding the care of my pet shall only be released to me or the co-owner/co-agent listed above unless I give written consent to BCVH. *

I have read and understand.

I understand that I am financially responsible for any services or products provided and that payment is due in full at the time services are rendered for today's visit along with all future visits. Balances left unpaid, will accrue a 1.5% finance charge per month. I agree to be responsible for paying a $25.00 fee if my check is returned for any reason. I agree to pay a 33.3 % attorney fee if my balance (including any monthly finance charges) is turned over for collection. *

I have read and understand.

I understand that we require at least 24 hours advanced notice to cancel or reschedule an existing appointment. If less than 24 hours notice is received, our hospital policy is to collect a $100 deposit to reschedule and hold that next time slot. If canceling or rescheduling a sedated and/or surgical appointment, at least 48 hours of advanced notice is required due to the specific time allotments associated with these appointments. If notice is received less than 48 hours in advance, a $100 deposit will be required to reschedule and hold that new sedated/surgical time slot. In both cases, that deposit collected will be used towards the balance of that rescheduled visit although, it will be non-refundable in the case that another appointment is missed or cancelled within the policy time frame. We understand there may be times when unforeseen circumstances occur but by providing us adequate notice, we can accommodate other patients in need of care. *

I have read and understand.

Signature *

Date *

Online Forms

Online Form for New Clients/ New Patients

Previous Clinic Information

Pet Information

Pet Insurance*

Media Release

Receive Automatic Reminders

Book An Appointment

Your Pet's Organizer App

Save Notes, Pics & Much More

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Contact

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