Step 1 of 425%Name(Required) First Last Co-Owner Name First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Phone(Required)Secondary PhonePrevious ClinicPrevious Clinic PhoneMilitary Yes NoSenior Yes NoRecommended by Whom?Place of EmploymentHow Did You Year About Us? Website Clinic Sign Google Facebook Instagram Nextdoor Yelp Print Ad Referral OtherWho Can We Thank?Please specify.First PetSelect One:(Required) Dog CatNameBreedMicrochip#Date of BirthColorSexSpayed or Neutered (Fixed)(Required)Date of Vaccinations – DogRabiesDAPPBordetellaLymeLeptoCanine InfluenzaDate of Vaccinations – CatRabiesFELVFVRCPSecond PetSelect One (Second Pet): Dog CatNameMicrochip#BreedDate of BirthColorSexSpayed or NeuteredDate of Vaccinations – DogRabiesDAPPBordetellaLymeLeptoCanine InfluenzaDate of Vaccinations – CatRabiesFELVFVRCPThird PetSelect One (Third Pet): Dog CatNameMicrochip#BreedDate of BirthColorSexSpayed or NeuteredDate of Vaccinations – DogRabiesDAPPBordetellaLymeLeptoCanine InfluenzaDate of Vaccinations – CatRabiesFELVFVRCPDo you have Pet Insurance?(Required) Yes NoDo you give permission to use a picture/likeness of pet(s) in photos/marketing materials or social media Yes NoIf you elect to not allow release of any information, the only person we will communicate with is the actual owner(s) on file and written approval will be needed for anyone else other than required by lawDo you give permission to release vaccine history to third parties ie. groomer/boarding/other veterinarians? Yes NoDo you give permission to release the entire medical record to insurance companies? Yes NoType SignatureWritten Financial PolicyOur office accepts:Cash, Visa®MasterCard®American Express®Discover Card®CareCredit® Healthcare Credit CardHaven Veterinary Clinic requires payment to be due as services are rendered and do not offer payment plans. For patients with insurance we are happy to work with your carrier to maximize your benefit and provide you with the documentation you need to receive reimbursement for your treatment. Haven Veterinary Clinic does not accept any type of checks.Haven Veterinary Clinic Zoonotic Disease Exposure According to the US Government’s Centers for Disease Control (CDC), an estimate of 6 Million Americans are infected with diseases/parasites that are transmitted from pets (both dogs and cats) to humans. These are called zoonotic diseases and can cause potentially serious health problems in people including, but not limited to, skin rashes, intestinal disease, blindness, seizures, meningitis, kidney disease, and death. To help protect your family as well as your pet, we follow pet care guidelines established by the US Government’s Centers for Disease Control (CDC) and other national pet health organizations to make every effort to test for and/or prevent potential threats to human health that may be introduced by your pet. Any individual who is in contact with or share your pet’s indoor/outdoor environment is potentially at risk. The risk of human exposure to many of these disease/parasites can be greatly reduced by protecting the pet through proper immunization and parasite prevention. Please sign below that you have been made aware of the recommendations; and you understand the information given to you about the importance of intestinal parasite testing and control/prevention of diseases that may affect you, your family, or the community. I understand that refusal of any of these procedures leaves my pet and family members vulnerable to exposure to diseases/parasites that may cause serious illness or death, and I accept full responsibility for the decision.Date MM slash DD slash YYYY Signature(Required)Reset signature Signature locked. Reset to sign again CAPTCHAΔ
