Step 1 of 2 50% Client Information:Name* First Name Last Name Driver's License Your Date of Birth* MM slash DD slash YYYY Street Address* Street Address City State / Province / Region ZIP / Postal Code Email Address* * We are a paper-light practice, using email regularly! Your email address will only be used within our business and pharmacy services to send you reminders for your pets and information from the vet.Primary Phone*Select Primary Phone* Cell Home Work Secondary PhoneSelect Secondary Phone Cell Home Work Additional Contact:Name First Name Last Name Relationship to you Phone Number Payment Information Full payment is due at the time of service and a deposit may be needed prior to treatment depending on the services provided. We accept, cash, checks, and most major credit cards, including Care Credit. We do not bill or invoice our clients. There is a $25.00 fee for any returned checks. CARECREDIT & other credit/debit cards:Please read & initial in the box to confirm your understanding:We accept all major credit cards including CareCredit as forms of payment. To make our card payment policies standard, our office has adopted the same card payment policy that CareCredit enforces. Our policy is that card holders may not allow anyone else to use their card in their absence. The card holder MUST be present for EACH transaction & be able to show valid picture ID that matches the name present on the card.* Please initial here that you understand we CAN NOT make exceptions to CARECREDIT's policy and will require card holders to be present with photo ID in order to use their CareCredit cardHow did you hear about us?* Release of Information:It is our policy to automatically share/release our patient’s records to other animalrelated businesses that ask for them. We extend this professional courtesy to groomers, boarding facilities, other vet offices, and specialists for the welfare of our patients. If you would like to opt out of this policy, and would rather we call you for approval before releasing your pet’s records, please initial here: Authorization of Ownership: I authorize the following people to act as owner in my absence and on my behalf for any of my pets listed in my medical record at KFVP. The decisions these people are able to make include, but are not limited to, authorizing medical treatments/procedures required or recommended for my pet(s), authorizing the financial obligation that is a direct result of the treatment/procedure they authorized, consent or decline any DNR (Do Not Resuscitate) clause or euthanasia. I understand that the people below must be over 18 years old as they are acting on my behalf. I also understand that any costs accrued on my account are payable by me as I am the official owner of my pet(s) listed as patients at KFVP People approved to act on my behalf other than the additional contact already listed on page 1:Name Phone NumberName Phone Number Prior Veterinary Care:Previous Veterinary Hospital/Doctor Previous Hospital's City & Phone # Do you have Pet Insurance, if so please list
