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Appointments at Winter Park Veterinary Hospital

407-644-2676

1601 LEE ROAD, WINTER PARK FL 32789

View Winter Park Veterinary Hospital Map

WPVH - New Client Form

HomeForms • WPVH New Client Form

NEW CLIENT INFORMATION

Thank you for giving us the opportunity to care for your pets. So that we may become better acquainted, please complete the following:

All fields are required [*]

Last Name:[*]

First Name:[*]

Middle Initial:

Address:[*]

Unit:

City:

St:

Zip:[*]

Primary Phone: [*]

Secondary Phone:

Email: [*]

*E-mail is required for important hospital communication and will never be sold or distributed to outside sources.
** Client agrees to any additional charges that may apply from their phone company when receiving text messages.


SECONDARY CONTACT

Last Name:

Firts Name:

Middle Initial:

Primary Phone:

Relationship:


REFERRAL INFORMATION

How did you become aware of our hospital?

Personal Recommendation:

Please note which client so that we may thank them for the referral.

Other Veterinarian:

Please note which client so that we may thank them for the referral.

Pet Store:

Please note which client so that we may thank them for the referral

Internet?


PATIENT INFORMATION

Pet Name:[*]

Trupanion/Pet Insurance:

Species: [*]

Breed:

Color:

Age/Birth Date:[*]

Sex: [*]

Spayed/Neutered? [*]

Name of Previous Vet:

May we contact your previous vet for your pets medical records?


ACKNOWLEDGEMENTS

Please Initial


Payment is expected at the time services are rendered. All charges must be paid in full prior to discharge. We accept cash, American Express, Discover, MasterCard, VISA, and Care Credit. There is a $25.00 returned check fee and collection will be actively pursued.


I agree, in the event that any amount becomes past due more than 30 days, I will pay interest thereon at 18% per annum (1.5% per month). In the event it becomes necessary to collect fees through the services of an attorney or other collection agency, either prior to or at trial, I agree to pay all reasonable attorney’s fees and/or collection agency fees, and reasonable attorney’s fees incurred.


We encourage you to ask our receptionist about the cost of general services as well as to review and discuss with your doctor the estimate for your pet’s treatment plan, so that you have time to make any necessary arrangements and ask questions. You can further discuss any potential risks and benefits of procedures. No medicine is an exact science and thus no guarantee of successful treatment can be made.


WPVH is committed to providing comprehensive, excellent veterinary services for your pet. We understand, at times, it may be necessary to discuss alternate forms of treatment. We are happy to help you explore these alternatives in order to arrive at the best plan for your family and pet.


A deposit of 75% of maximum estimated total for surgery, dental, extensive treatment, hospitalization and/or first-time boarding is required at the time your pet is admitted. Please keep your of estimates. Remaining balance is due prior to discharge. Estimates are honored for 30 days.


Fee estimates are approximations of expected medical costs and can vary significantly. We will attempt to contact you regarding significant change in treatment/fees as they occur. It is essential you leave us with phone numbers where you can be contacted quickly.


We strongly suggest you ask daily about current charges during your pet’s hospitalization in that they can change, and at times, increase significantly, based on the medical status of your pet. This is especially important prior to your pet’s discharge appointment so that you can have any questions you might have answered.


We are happy to reschedule your pet’s appointment with a minimum of 24-hours notice. Without this notice, it is necessary to charge a cancellation fee of $30 to $50 to account for doctor/technician time and surgical equipment reserved exclusively for your pet. This also applies to boarding reservations.


I have read and agree to the financial requirements and terms detailed above for all animals I bring to WPVH.


I acknowledge I am the owner or authorized agent of the above named pet and I am over the age of 18. [*]


Date [*]



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