Request an Appointment

Request an Appointment

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- New Client Form
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New Client Form

Welcome new clients!

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooperation in letting us assist you.

Download New Patient Form

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"*" indicates required fields

Pet Owner/Client Information:

Please note: Government-issued picture identification will be requested to verify identity for establishing an account.

First Name

Last Name

Initial

Address**

Street Address* City* State* Zip Code*

Cell Phone**

Home Phone**

Work Phone**

Ext

Email Address

Employer

Secondary Contact:

First Name

Last Name

Relationship

Cell Phone

Home Phone

Work Phone

Ext.

Driver’s License number

Date of Birth

MM slash DD slash YYYY

Please indicate how you heard of us

MVH Website

Marquee

Phone Book

AAHA

Friend

Other

Friend Name

Other

If personal referral, whom may we thank?

Are you or your spouse

Military

Veteran

Police

Firefighter

Pet Information: (For more than one pet, ask for additional pet form)

Pet's Name

Species

Breed

Color

Microchip #

Date of Birth

MM slash DD slash YYYY

(please estimate if unknown)

Age

Sex

Neutered or Spayed

Is your pet the best pet in the whole world?

Yes

No

Pet’s Diet

Any special diets

List current medications and/or medical conditions

List any previous illnesses or surgeries

Does your pet have any allergies?

Has your pet had heartworm testing? On prevention medication (what kind)

Is your pet on flea and tick prevention (what kind)

Please check any symptoms your pet is currently showing

Coughing

Sneezing

Breathing problems

Diarrhea

Constipation

Urination decrease/increase

Scooting

Vomiting

Appetite loss

Change in activity level

Behavioral changes

Limping

Shaking head or ears

Scratching or itching

Change in thirst

Rash

Loss of balance/weakness

Unusual mass

Eye problems

Cut or injury

Describe Any Other Areas of Concern:

300 words max

I Approve My Pet’s Picture and Their First Name to be Used in Social Media

Yes

No

Please bring in a stool specimen so we can check for parasites

Authorization

I authorize the veterinarian(s) to examine, prescribe for, or treat the pet(s) listed above. I assume responsibility for all charges incurred in the care of this/these animals(s). I understand every reasonable effort will be made to provide for successful treatment; however, due to the nature of some conditions, no guarantee can be made of a successful outcome. I understand charges are to be paid at the time of services and a deposit may be required prior to treatment. I understand that any pictures taken of my pets are property of MVH, LLC, and can be used at the company’s discretion. I agree to pay interest charges of 18% APR (1.5% per month) for any balance over 30 days past due. Should collection efforts become necessary, I further agree to pay the reasonable costs incurred in the process of collections. I also agree to pay a non-sufficient funds (NSF) fee of $25.00 or the maximum allowed by state law for any returned check, and this fee along with full check payment may be electronically withdrawn from my bank account.

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About Us
Services
New Clients
- New Client Form
Resources
Contact Us

About Us
Services
New Clients
- New Client Form
Resources
Contact Us

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