New Client Application

Thank you for choosing Family Pet Health Center to be a part of your pet’s health care team! Our mission is to partner with families to make a difference in the lifetime of their pets through compassionate and personalized care. In order for us to provide you with exceptional service, please share some information about you and your pet(s).

Client Name(Required)

First Last

Other responsible party name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Primary Phone Number(Required)

Can this phone number receive text messages?(Required)

Yes

Secondary Phone Number

Can this phone number receive text messages?(Required)

Yes

Email Address(Required)

Driver's License Number

How did you hear about us?

Name of referring clinic?(Required)

Whom can we thank?(Required)

Do you want to add an emergency contact?(Required)

Yes

Emergency Contact Name(Required)

First Last

Emergency Contact Phone Number(Required)

Names and ages of other members of the household

Pet Information

Pet's Name(Required)

Dog or Cat(Required)

Dog

Cat

Breed(Required)

Color(Required)

Sex(Required)

Male

Neutered Male

Female

Spayed Female

Pet date of birth or approximate age(Required)

Is your pet microchipped?

Yes

Other

In order to give you and your pet the most well-rounded care, we need access to your pet’s complete previous medical history.

Name of previous veterinary clinic(s)

Phone number of previous veterinary clinic(s)

We would love to get to know your pet better prior to your visit. Please upload a picture of your companion and tell us what makes them special and how they generally feel when visiting the vet. We want to make their first visit with us comfortable and positive!

Upload Images

Drop files here or

Max. file size: 25 MB.

What makes your pet special?

Where did you get your pet?

How long has your pet been part of your family?

Please list any other pets in the household

Describe your pet’s diet. What pet food do you feed? How much and how often? What treats does your pet get? Does your pet get human food?

Is your pet taking currently taking any medications? Please list medication name, dose, and frequency.

Does your pet have any known allergies to medications, foods, or the environment?

How much time does your pet spend outside?

Does your pet participate in any of the following activities? Check all that apply

Boarding / Grooming / Daycare / Dog parks

Training classes

Animal sports

Hunting

Swimming in lakes or streams

Hiking

Is your pet a registered service animal or therapy animal?

Yes

Is your pet currently on heartworm prevention?

Yes

Heartworm medication and frequency(Required)

Is your pet currently on flea preventative?

Yes

Flea preventative medication and frequency(Required)

Has your pet ever had a dental cleaning?

Yes

Visit Information

What is the reason for your first visit with us?

Please choose any of the following that are a concern / interest to you regarding your pet's behavior / health:

Other(Required)

Are you requesting a specific doctor?

Agreements

Occasionally we will photograph our patients and publish photos on our website, Facebook, or other publications. Please choose an option below indicating whether or not we may use your photos:

Yes, you have my permission to publish photos of my pet

Yes, you have my permission to publish photos of me

No, please do not public photos of my pet

No, please do not publish photos of me

We often receive calls indicating that someone has found your pet or needs information in regard to your pet. Due to privacy laws, we need your permission to give out your information – such as your name, telephone number, and your pet’s vaccine status. Please know that your privacy is one of our top priorities and we would give out information only as it relates to the situation.

By choosing yes below, you are authorizing us to give out such information if needed. Please note that if one of the local animal control facilities were to contact us, we may be required to give out your contact information regardless of the option chosen below.

Can we give out this information in these cases?(Required)

Yes, you have my permission to give out my information

No, please do not give out my information

Our team promises to:

Treat our patients, clients and community with respect and dignity
Approach every interaction with honesty, kindness, compassion and professionalism
Provide a safe, clean environment for our patients
Maintain a caring, comfortable and safe atmosphere for our clients
Increase the knowledge and talent of our team to bring the highest level of comprehensive veterinary care to our patients
Increase the quality of life for our patients through preventative health care, reliable client education and relief of pain and discomfort

The client/patient/veterinary relationship is at the heart of everything we do at Family Pet Health Center. Our goal is to keep your pet healthy through prevention and education and to treat/manage illnesses as they arise. We maintain a high standard of care by recommending regular examinations for annual wellness assessments and vaccines, as well as for the diagnosis of illnesses. An accurate diagnosis may require diagnostic testing and the management and/or resolution of illnesses may require follow-up exams or diagnostic testing. We define a current doctor/patient relationship as a patient having had a comprehensive physical exam by a Family Pet Health Center veterinarian within the previous 12 months.

Please choose from the following options(Required)

I agree with the above standard of care. I commit to bringing my pet for regular examinations, listening to the doctors recommendations, asking questions as I need to, and working as a team with the staff at FPHC to create the best plan for my pet and family.

I have some questions about these recommendations and would like to be contacted by a member of the FPHC team. Together we will determine if this type of veterinary care is appropriate for my pet.

I only want basic veterinary care for my pet.

Other

In order to maintain a positive and productive relationship, we require the following: • Professional fees are due at the time of service. We accept cash, checks, Visa, Mastercard, Discover, American Express, and CareCredit. • Nonrefundable deposits are required for first new client visits, anesthetic procedures, and hospitalized care. • We will gladly provide written estimates for care prior to providing services at your request. Our goal is to provide your pet with thorough care that fits your family’s needs. If you require an estimate, please request one before agreeing to treatment. • If you need to cancel or reschedule an appointment, we require 24 hours notice (72 hours for anesthetic appointments). With the exception management deemed extenuating circumstances, all appointments that are canceled or rescheduled within 24 hours of the appointment time (72 hours for anesthesia appointments) or are no shows will be assessed a cancellation fee. The cancellation fee must be paid in full before rescheduling the next appointment in these situations. • Twenty-four business hours notice is required for refilling medication and food orders. • All Family Pet Health Center team members, clients and patients must be treated with respect at all times. • For the safety of our patients, clients, and staff, pets must be leashed or in a carrier while in the parking lot, lobby, hallways and any other area of the clinic where they may encounter other people and pets. Retractable leashes must be in the locked position with no more than six feet of lead length. • Any concerns regarding your pet’s care or our client service will be addressed respectfully with a member of the management team. • Punctuality for appointment times. • Please understand that emergencies and urgent visits may unexpectedly affect our schedule. We ask for your understanding as we provide life-saving care to these pets and remember that we will do the same for your pet if/when the need arises.(Required)

In order to maintain a positive and productive relationship, we require the following:
• Professional fees are due at the time of service. We accept cash, checks, Visa, Mastercard, Discover, American Express, and CareCredit.
• Nonrefundable deposits are required for first new client visits, anesthetic procedures, and hospitalized care.
• We will gladly provide written estimates for care prior to providing services at your request. Our goal is to provide your pet with thorough care that fits your family’s needs. If you require an estimate, please request one before agreeing to treatment.
• If you need to cancel or reschedule an appointment, we require 24 hours notice (72 hours for anesthetic appointments). With the exception management deemed extenuating circumstances, all appointments that are canceled or rescheduled within 24 hours of the appointment time (72 hours for anesthesia appointments) or are no shows will be assessed a cancellation fee. The cancellation fee must be paid in full before rescheduling the next appointment in these situations.
• Twenty-four business hours notice is required for refilling medication and food orders.
• All Family Pet Health Center team members, clients and patients must be treated with respect at all times.
• For the safety of our patients, clients, and staff, pets must be leashed or in a carrier while in the parking lot, lobby, hallways and any other area of the clinic where they may encounter other people and pets. Retractable leashes must be in the locked position with no more than six feet of lead length.
• Any concerns regarding your pet’s care or our client service will be addressed respectfully with a member of the management team.
• Punctuality for appointment times.
• Please understand that emergencies and urgent visits may unexpectedly affect our schedule. We ask for your understanding as we provide life-saving care to these pets and remember that we will do the same for your pet if/when the need arises.

I have read, understand, and agree to the above statement.(Required)

E-Signature(Required)

Date(Required)

CAPTCHA

New Client Application

Pet Information

Visit Information

Agreements

Expert Veterinary Care in South Bend, IN