New Client Form

Today's Date(Required)

Name(Required)

First Last

Partner/Spouse/Guardian Name

First Last

Preferred Number(Required)

Texting (SMS) okay?(Required)

Yes

Home/Work Number

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer

Occupation

How did you hear about us?

Patient/Pet Registration

Patient Name(Required)

Name

Date of Birth

Age(Required)

Gender(Required)

Male

Female

Spayed/Neutered(Required)

Yes

Breed(Required)

Color

Current Medications and times given per day(Required)

Preferred Pharmacy(Required)

Current Supplements and times given per day(Required)

Pet's current diet (including brand if applicable)(Required)

Known allergies to food, medication or other(Required)

Rabies Vaccination up to date?(Required)

Yes

Has your pet had any adverse reactions to any medications?

Primary Veterinarian's Name

Name

Name of primary hospital(Required)

Consent

General Consent – I authorize Veterinary Cancer Care, P.C., along with the attending veterinarian and their team, to provide the treatments and perform the procedures discussed with the doctor.(Required)

I acknowledge that all procedures and treatments carry inherent risks, and I commit to discussing any concerns about those risks with the attending veterinarian prior to proceeding.

I also consent to, and acknowledge that some of the medications or treatments administered to my pet may be used in an ‘off-label’ manner for the treatment of their specific medical condition.

I agree to allow only authorized adults (18 years or older) to bring my pet in for treatment and services. Additionally, I understand that Veterinary Cancer Care may adjust fees, with advance notice, for reasons including, but not limited to, industry standards, supply and demand, inflation, contracted medical personnel, and other professional considerations.

Financial Consent(Required)

I agree to assume full and complete financial responsibility for the balance of ALL services rendered at the time my pet is discharged. This means paying for the associated fees in full by cash, card, or check made payable the same day. I acknowledge that any estimates presented to me are not a guarantee of final charges and agree to pay for all services and treatments provided to my pet. I understand that it is my responsibility to obtain any necessary financing from an outside source, confirm the funds are immediately available for use, and know my limits BEFORE authorizing care. I acknowledge that Veterinary Cancer Care has the right to refuse me services should I be unable to provide payment in full. Any outstanding balances that do not have a written payment plan on file, will be required to be paid in full in order to proceed with future scheduling, services, and treatments. Balances cannot be carried forward. Payment is due in full at the time of services, including previous balances. Accounts with previous balances will be required to pay in full to schedule new visits or services.

Payment is due in full at the time that services are performed. We accept credit cards (Visa, Mastercard, Discover, American Express), cash, check, insurance, iCare, Scratch Pay, and CareCredit payments. We neither extend credit, nor bill for services. All open invoices are sent to collections after 45 days unless prior arrangements are made.(Required)

I have read and accept the financial policy.

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Patient/Pet Registration

Consent

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