New Client Form New Client Form Thank you for trusting in us and allowing us to provide emergency medical care for your pet today. We understand that this may be a difficult time for you and your pet, and that your visit today and its associated fees are unexpected. Our goal is to provide your pet with high quality compassionate medical care and to communicate thoroughly with you regarding our recommended medical plan and the associated costs. Please note, the cost of the emergency consultation today is $200 and is due at the time of service. This does not include any recommended treatments or diagnostics. Checking the box below indicates that you are aware of the $200 consultation fee and understand that payment is due at the time of service. * I am aware of the $200 consultation fee and understand that payment is due at the time of service. Name * Name First First Last Last Address * Address Street Street Apt/Suite Apt/Suite City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip Email * Phone (home) * Phone (cell) * Are you over 18 years of age? * Yes No Pet Information Pet's Name * Species * CanineFelineOther Gender FemaleFemale (spayed)MaleMale (neutered) Breed * Color * Age / Date of Birth * Briefly describe why your pet is here today * Your Pet's Veterinarian As an emergency referral center it is our responsibility to care for your pet while your veterinarian is unavailable. Therefore, it is important for us to share our medical records with them. Please provide us with your veterinarians contact information so that we can send your pet's records to them in a timely fashion. Please select one option * My pet is an established patient of the veterinary hospital below My veterinarian has not yet seen this pet I do not have a regular veterinarian yet Veterinarian Name Hospital Name Your check here authorizes us to send your pet's medical records to the above named veterinarian * Authorize The Veterinary Medical Center does not receive funding from any state, county, or local programs. We are unable to provide billing services and must have a deposit prior to rendering services. Full payment is required upon receipt of service. We do not provide billing services, and we do not hold checks. We require a 75% deposit of the higher end of the estimate at the time of admission for hospitalization or outpatient treatment. We accept cash, checks, and credit cards. We offer various independent third party payment plan options. You must apply for and be approved for those options. Please ask one of our staff about applying for the payment options that are available if you are interested. The doctors and staff are not authorized to make changes to the hospital’s payment policy. * I have read and understand the financial policies of the Veterinary Medical Center of CNY. I certifiy that I am the owner of or the agent of the owner of the aforementioned pet. I further understand that I agree to the terms of payment above and if I default on this agreement I may be subject to collection and all reasonable attorney's fees incurred. If you are human, leave this field blank. Submit
