Home
About
Our Team
Reviews
Learning Center
What is a Veterinary Dermatologist?
Custom Medication
Careers
Clinic Photos
Our Process
Services
RX Refills
In-House Refills / Deliveries
Appointment
FAQ
Contact
Select Page
New Client Information Form
Complete the form below prior to your first visit!
Please enable JavaScript in your browser to complete this form.
12:00 speak Information)
Owner Information
Name
*
First
Last
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
*
Cell phone
*
Home phone
Work phone
What is your preferred method of contact for general communication?
*
Email
Cell Phone
Home Phone
Work Phone
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?
Veterinary Referral
Referred by a Friend
Google
Yelp
Facebook
Instagram
Other
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
For initial consultations (first appointment), cancellations must be made at least 24 hours in advance to avoid forfeiting the prepaid consultation fee. (Please note: Monday appointments must be canceled by 12:00 p.m. the Friday prior.) For recheck appointments, cancellations or reschedules must be made at least two business days in advance. Late cancellations or no-shows will incur a cancellation fee. A 10-minute grace period is granted for each scheduled appointment. Arriving more than 10 minutes late may result in forfeiture of the appointment time and cancellation of your visit. After booking your initial consultation, your credit card will be securely 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
*
Clear Signature
Submit
