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About
General Care
Advanced Medicine
Wellness Center
- Canine Care
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Doggie PlayCamp
Resources
Contact

(407) 644-2676

1601 LEE ROAD,
WINTER PARK, FL 32789

Veterinarians in Winter Park, Orlando FL

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New Client Form

New Client Form

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

Marked Fields are Required [*]

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- Winter Park Veterinary Hospital
- Winter Park Vet Wellness Center
New Client Information
Date
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Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone*
** Client agrees to any additional charges that may apply from their phone company when receiving text messages.
Secondary Phone
Email*

*E-mail is required for important hospital communication and will never be sold or distributed to outside sources.
Secondary Contact
Name
First Last
Primary Phone
Relationship
Referral Information
How did you become aware of our hospital?*
- Drove by
- Yellow Pages
- Chamber of commerce
- EAGO
- Previous client - WELCOME BACK!
- Personal recommendation
- Veterinary Referral
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- Internet search
Who shall we thank?*
Please note which client so that we may thank them for the referral.
Please tell us her/his name:*
Please tell us which store:*
Please select one:*
- Google
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Patient Information
Pet Name*
Trupanion/Pet Insurance*
Species*
- Canine
- Feline
- Avian
- Small Mammal
- Reptile
- Other
Can you tell us what species your pet is?*
Breed
Color
Age/Birth Date*
Gender*
- Male
- Female
- Undetermined
Spayed/Neutered?*
- Yes
- No
- Undetermined
Name of Previous Vet
May we contact your previous vet for your pets medical records?
- Yes
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Any other comments you may want the Veterinarian to know:
ACKNOWLEDGEMENTS
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 acknowledge and agree
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.*
- I acknowledge and agree
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.*
- I acknowledge and agree
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.*
- I acknowledge and agree
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.*
- I acknowledge and agree
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.*
- I acknowledge and agree
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.*
- I acknowledge and agree
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 acknowledge and agree
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. [*]
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Veterinarians in Winter Park

Winter Park Veterinary Hospital

1601 LEE ROAD WINTER PARK, FL 32789

(407) 644-2676

Local Vet Near You Offering Veterinary Care for Dogs, Cats, Birds, Reptiles, Small Mammals in Winter Park, Maitland, Orlando, FL Veterinarians near Maitland | Veterinarians near Baldwin Park FL | Veterinarians near College Park FL |Veterinarians near Orlando | Veterinarians in Winter Park FL

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