Consent - New Patient Owner's Name(Required) First Last Pet's Name(Required)Please enter one at a time. A link to register more will be appear after you hit submit. Sex, Color, and Breed*(Required)Examples: female spayed yellow lab....male intact brown golden doodle....random cat i found gender TBD Date Of Birth(Required)If unknown, choose a favorite date or select Jan 1st of approximate year. MM slash DD slash YYYY Previous Veterinary Clinic Names:(Required)We'll request records to make your life simpler. Primary Reason for Requesting Appointment:(Required)Example: Vaccines, Allergies, Limping on Back Left Leg, etc. Has your pet had or displayed any of the following? Allergic reaction to medicine or vaccine Food Allergy Surgical procedure(s) other than spay/neuter Major hospitalization or Illness Fear at a vet clinic Threatening to bite or nip Please explain any checked boxes above:(Required)Is there anything special we can do to make sure you and your pet has an enjoyable veterinary experience?Examples: I always want to be in the room with my pet for all procedures, or....I'm likely to faint if I see a needle so take my pet away for vaccines, or.... my pet loves cheese so bring out the yummies, or...my pet hates having its belly tickled How did you hear about us? *(Required) Referred by a friend Google search Flyer in the mail Other Please review our clinic policies below. Late Exam Cancellations: We are often forced to turn away pets in need of care if our available time is reserved for other pets. We therefore ask for at least 24 hours notice for exam cancellations to plan accordingly. If we are unable able to fill the slotted time reserved for your pet due to a late cancellation, you will incur a fee equivalent of an exam fee. Late Surgery Cancellations: Multiple hours for multiple team members are reserved for each surgical procedure. We ask for 7 days notice on surgical cancellations or reschedules. If less than 7 days notice is given and we are unable to fill the appointment time, a $100 late cancellation fee will be charged. Payment Method on File: A credit card on file is required for all appointments. Credit cards are stored securely as tokens in the medical records system and team members cannot see the credit card numbers to protect the card holder.Prescription Refill Requests: We do our absolute best to fill refill requests as soon as possible, but ask for 48 hours notice. We promise to text you when the medication is ready for pickup. Payment: Payment is due at the time of service rendered. A lack of payment will be considered theft of services and submitted to law enforcement. Audit Process: We are diligent in our invoicing, but errors can occur. If your pet receives a service or product which was not charged during the visit, after the visit you may receive an additional invoice for services rendered. Emergency Services: Crossroads Animal Hospital is not staffed to provide after hours services, but we partner closely with nearby emergency facilities. We encourage you to familiarize yourself with locations near your home, additional resources can be found at www.crvet.org/ER. Preventative Health Guidelines: All recommendations are made in accordance with either the American Animal Hospital Association Guidelines, Companion Animal Parasite Council, or the American Association of Feline Practitioners Guidelines. Fear Free Policies: All efforts are made to ensure your pet has a comfortable and fear-free experience. If our team decides that continued care or restraint may result in excessive fear or injury we reserve the right to decline treatment in the best interests of your pet. Considerate Behavior: We promise to always treat you and your pet with respect and compassion. We ask that the same sentiment is returned when dealing with any member of the staff and reserve the right to refuse services if necessary. These policies are subject to change. Consent I agree to the above listed policies. Δ
