Client Information Form - Bayview Veterinary Center

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Owner's Information

Full Name*

First Last

DOB*

MM slash DD slash YYYY

(required for controlled substance dispensing)

Address*

Street Address City State ZIP Code

Email*

Phone (Home)*

Phone (Mobile)

Do you want to add your Spouse/Partner information?*

Yes

Spouse/Partner Information

Spouse/Partner Full Name

First Last

Spouse/Partner DOB

MM slash DD slash YYYY

(required for controlled substance dispensing)

Spouse/Partner Email

Spouse/Partner Phone (Home)

Spouse/Partner Phone (Mobile)

Pet Information

Pet's Name*

Species*

Breed*

Date of Birth or Age*

Sex*

Male

Female

Spayed/Neutered*

Yes

Color/Markings*

Do you have a Pet Insurance?*

Yes

Name of Pet Insurance*

This field is hidden when viewing the form

Is your pet up to date on vaccinations?*

Yes

This field is hidden when viewing the form

List any on-going, chronic medical history for your pet*

This field is hidden when viewing the form

List any current medications or supplements your pet is taking*

Add a second pet?*

Yes

Second Pet Information

Pet's Name*

Species*

Breed*

Date of Birth or Age*

Sex*

Male

Female

Spayed/Neutered*

Yes

Color/Markings*

Pet Insurance*

Is your pet up to date on vaccinations?*

Yes

List any on-going, chronic medical history for your pet*

List any current medications or supplements your pet is taking*

Add a third pet?*

Yes

Third Pet Information

Pet's Name*

Species*

Breed*

Date of Birth or Age*

Sex*

Male

Female

Spayed/Neutered*

Yes

Color/Markings*

Pet Insurance*

Is your pet up to date on vaccinations?*

Yes

List any on-going, chronic medical history for your pet*

List any current medications or supplements your pet is taking*

Veterinary Records

To help us ensure that we are able to review your pet’s complete medical history, previous veterinary records are required prior to appointment. Please provide the Clinic’s name and contact information of your previous veterinarian, if applicable, and we will request records on your behalf.

Clinic's Name*

This field is hidden when viewing the form

Phone*

Appointment Cancellation Policy

Notice of Cancellation:
We kindly request that you provide at least 24 hours’ notice if you need to cancel or reschedule your appointment. This allows us to offer the appointment slot to another pet in need of care.

Late Cancellation or No-Show:
If you need to cancel your appointment with less than 24 hours’ notice or fail to attend your scheduled appointment without prior notice, a cancellation fee may be applied. The fee amount will depend on the nature of the appointment and may be equivalent to the cost of the appointment.

Rescheduling Appointments:
If you need to reschedule your appointment, please contact our clinic as soon as possible to find an alternative appointment time that suits your schedule. We will do our best to accommodate your needs.

Emergencies:
We understand that unforeseen emergencies can occur. In such cases, please notify us as soon as possible, and we will work with you to reschedule your appointment without a cancellation fee.

Confirmation Calls and Reminders:
We provide appointment confirmation calls or reminders as a courtesy to our clients. However, the responsibility for keeping the appointment and providing cancellation notice remains with the pet owner.

I have read and understand the Appointment Cancellation Policy at Bayview Veterinary Center.*

I have read and understand the Cancellation Policy

Payment Policy

At Bayview Veterinary Center, we are dedicated to providing the best care for your beloved pets. To ensure a smooth and efficient payment process, please take note of our payment policy:

Payment Due at the Time of Service
Payment is expected at the conclusion of each visit. This allows us to continue delivering top-notch care to your pets.

Acceptable Forms of Payment
We accept the following forms of payment:

Cash
Check
Credit Cards (Visa, MasterCard, American Express, Discover)
CareCredit

Deposits for Specialized Services
In some cases, services provided by board-certified veterinary specialists may require a deposit to secure your appointment and cover associated costs. These services may include advanced procedures or treatments that necessitate the involvement of external specialists.

The deposit amount and specific conditions will be discussed with you in advance of scheduling the appointment. Please be aware that deposits are non-refundable unless otherwise specified during the appointment scheduling. These measures ensure that the necessary resources and preparations are in place to deliver the best care for your pet during these specialized services.

Payment Plans
Please be aware that we do not offer payment plans. We kindly request payment in full at the time of service.

Estimates
Upon request, we are more than happy to provide you with an estimate for the services required. This will give you a clear understanding of the costs involved in your pet’s care.

Insurance
We also accept pet insurance. If you have pet insurance, please provide us with the necessary information, and we will assist you in processing your claim.

We appreciate your understanding and cooperation in adhering to our payment policy. If you have any questions or need further clarification, our friendly staff is here to assist you. Your pet’s well-being remains our top priority.

I have read and understand the Payment Policy at Bayview Veterinary Center.*

I have read and understand the Payment Policy.

Photography Consent

I, the undersigned, hereby grant Bayview Veterinary Center the right to photograph my pet for the purposes of marketing and social media promotion. I understand that these photographs may be used in various promotional materials, including but not limited to, brochures, websites, social media accounts, and other marketing materials.

I acknowledge that my pet’s likeness may be used to showcase the exceptional care and services provided by Bayview Veterinary Center. I release any claims to compensation for the use of these photographs.

I understand that the privacy and welfare of my pet will be respected at all times, and any sensitive or inappropriate images will not be shared.*

I confirm my consent to this photography release

I DO NOT consent to this photography release

Anti-Defamation Statement

At Bayview Veterinary Center, we value open and honest communication with our clients and are always striving to improve our services. However, we also recognize the importance of maintaining a respectful and professional relationship.

We kindly request that our clients refrain from posting untrue, defamatory, or malicious statements about Bayview Veterinary Center on online forums or social media platforms. We understand that concerns or grievances may arise from time to time, and we encourage you to discuss these matters directly with our staff or management to address any issues or misunderstandings.

Posting untrue or defamatory statements online not only harms our reputation but can also hinder our ability to provide the best care for your pet. We take such statements seriously and reserve the right to consider such actions as a breach of trust, which may lead to the severance of the veterinarian-client-patient relationship.

Our goal is to maintain a respectful and collaborative partnership with all our clients to ensure the well-being of your pets. We appreciate your understanding and cooperation in this matter and encourage open and constructive dialogue to address any concerns.

Thank you for entrusting us with the care of your furry family members.

I have read and agree to abide by the Anti-defamation Statement at Bayview Veterinary Center.*

I have read and understand the Anti-Defamation Statement

How did you hear about Bayview Veterinary Center?*

Online Search

Referral

Social Media

Other

Please provide the First and Last Name of the person who referred you.*

Is there anything specific you would like to discuss with the veterinarian at your appointment?*

Signature – Please enter your Full Name*

I, the undersigned, certify that the information provided is accurate to the best of my knowledge.

Signature Date*

MM slash DD slash YYYY

Thank you for choosing Bayview Veterinary Center. We look forward to providing excellent care for your pet.