Owner Information

Name *

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Address *

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Email *

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What is your preferred method of contact for general communication? *

Please list any person who is authorized to make medical or financial decisions regarding this patient. *

For initial exams, we require at least one owner present

How did you hear about us?

Name of friend *

Please specify. *

Authorization and Payment Policy

I hereby authorize the veterinarian to examine, prescribe or treat the above patient. I assume full responsibility for all charges incurred in the care of this animal. I also understand that these charges are to be paid in full at the time of release. Payments are expected when services are rendered. WE DO NOT BILL. In order to provide the best care, we accept: all major credit cards (MasterCard, Visa, Amex, & Discover), Care Credit, and cash. Should collection and/or attorney’s fees become applicable I will be held responsible for those and all other costs of collection. By signing below, I hereby state that I am the owner or authorized agent of the above patient. We are teachers in the field of veterinary dermatology. Medical files, case information and/or photos may be used in teaching, continuing education, website, veterinary literature, and the like. I authorize the release of case/patient information for such purposes; client confidentiality (Names and Personal Information) will be maintained. I understand that no guarantee can be made as to the result obtained from medical treatment. I have read the above terms and conditions and agree to adhere to this agreement. *

I agree

Cancellation and Late Arrival Policies

Please note our cancellation and late arrival policies: A 15 minute grace period is granted for each appointment time. Arriving past this grace period may forfeit the appointment time, and your appointment may be canceled. Should your initial consult appointment be canceled less than 24 hours prior to your pet’s exam (Monday exams must be canceled by 12:00 pm on the Friday before the appointment), you will forfeit your prepaid consultation fee. For future recheck late cancellations or no-shows, you will be charged a $50 cancellation fee. After booking your initial consult, your credit card will be kept on file. *

I understand

Online Pharmacy Policy

Please note our online pharmacy policy: We do not deal directly with online pharmacies. We have had problems with patient monitoring as well as incorrect medication instructions in the past. We will provide a written prescription upon request, provided we have recently examined your pet and the particular medication or product is appropriate. Written prescriptions can be picked up during your appointment time or during normal business hours. *

I understand

Client Communication Policy

Please note our client communication policy: For all consultations, the pet’s owner and financial decision-maker must be available to speak with the doctor either in person or over the phone during the appointment. If the primary decision-maker is not available to speak with the doctor during the appointment time, the doctor will formulate a plan with their best recommendations based on the information provided. In an effort to serve all our patients, if additional time is needed to reformulate the plan because the primary decision maker was not available during the appointment, additional exam time must be scheduled. *

I understand

Cytology

Please note our cytology policy: Be prepared for additional cytology testing during the examination. In our clinic, 95% of cases require cytology during the exam. Cytology is a sample of the skin or ears examined on a glass slide to look for types of skin cells, types of infections, and types of inflammatory cells. Cytology is a tool that directs the veterinary dermatologist to the best plan of action. An estimate will be provided after the exam and cytology for any additional items (cultures, lab work, biopsy, medications, etc.). *

I understand

Signature *

New Client Information Form

Owner Information

Authorization and Payment Policy

Cancellation and Late Arrival Policies

Online Pharmacy Policy

Client Communication Policy

Cytology

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