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New Patient Registration Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

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Client Information

Name
Address
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Is This Your First Visit to Veterinary Referral & Critical Care?
How did you hear about us?
Do you or does anyone in your family have a peanut allergy?

Patient Information

Do you have Pet Health Insurance?
Sex
Species
Are all vaccinations currently up to date?
By checking this box I understand that I will have a consultation with the specialist prior to initiating any diagnostic or treatment procedures. An estimate will be provided at my request. I have the right to decline treatment and care prior to it being administered. I further understand that I am responsible for a deposit totaling 100% of the low end of the estimate prior to services being rendered and payment-in-full of the remaining balance upon discharge of my pet from the Veterinary Referral & Critical Care. I hereby authorize Veterinary Referral & Critical Care to perform any and all medical services that they deem appropriate.
THE VETERINARY REFERRAL & CRITICAL CARE ENCOURAGES YOU TO TAKE ALL LEASHES, COLLARS, BEDDING, TOYS, ETC. WITH YOU AT THE TIME OF ADMISSION OF YOUR PET. WE WILL NOT BE RESPONSIBLE FOR LOST/MISPLACED ITEMS EVEN THOUGH MEASURES ARE TAKEN TO SECURE THEM.
I hereby give my consent for Veterinary Referral & Critical Care to take photos and/or videos of my pet for the purpose of posting on Veterinary Referral & Critical Care's social media and website. I hereby release and discharge Veterinary Referral & Critical Care from any and all claims arising out of use of the materials.
Due to the current post-COVID severe shortage of trained veterinary professionals throughout our industry, Veterinary Referral & Critical Care can no longer guarantee care for its patients over the weekends.  Veterinary Referral & Critical Care therefore has no choice but to close its hospital each Saturday and remain closed until Monday mornings due to a lack of qualified staff.
Effective the week of November 1, 2021, (therefore, beginning Saturday, November 6) our clients will be required to retrieve their pets from our facility by no later than 5:45 p.m. each Saturday.  Clients who do not pick up their pets by the required time will be charged a late fee of $100 for each and any time period up to thirty (30) minutes beyond the deadline that their pet remains at Veterinary Referral & Critical Care.  Therefore, if a client is exactly one hour late to pick up their pet, they will owe a $200 late fee.  Likewise, if a client is 45 minutes late collecting their pet, they will be charged a $200 late fee. If the client is 1.5 hours late to pick up, they will owe a $300 late fee. And so on.
Veterinary Referral & Critical Care is committed to providing only the highest level of service for the animals in our care, and under current labor shortage conditions, we simply cannot provide that level of care over the weekends.  We are implementing this late fee system to ensure that pet owners understand that their animals’ care is the pet owners’ responsibility over weekend periods.
By my signature below, I acknowledge that I have been informed of Veterinary Referral & Critical Care weekend policy. As a condition of Veterinary Referral & Critical Care treatment of my pet, I agree to the late fee structure set forth above should I fail to pick up my pet by the weekend closure time.
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