Owner's Name

Name*

First Last

Address*

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

Day-Time Phone*

Evening Phone

Mobile Phone

Email*

Enter Email Confirm Email

Co-owner's Name & Contact #

Name

First Last

Phone

How did you find out about our practice?

If Other, please specify:

If Personal Referral, is there someone we can thank for this referral?

Please use this area to give us any other relevant information about yourself or your family

Pet's Name*

Species*

or if other species

Breed (if known)

Color

Date of Birth or Age (if known)

Special Identification (tattoo, microchip, etc.)

Sex

Previous Veterinary Practice (if any)

COVID-19 Appointment Protocol*

I hereby acknowledge for the saftety of clients and staff, clients are not allowed in the building. Client are required to call the main number when arriving at the parking lot but remain in their vehicle. Mask are required to be worn for all face to face interactions and while entering the foyer to pick up medications. I understand PVC is only accepting credit cards no cash or check until further notice.

PHOTOGRAPH & PET INFORMATION RELEASE

I hereby grant PawSteps Veterinary Center (henceforth known as PVC), its representatives and employees the absolute and irrevocable right to use my pet's names and images for any lawful purpose, including for example such purposes as publicity, illustration, marketing, web content, and social media. I hereby acknowledge receipt of adequate consideration and waive the right to charge for use of the pictures, to inspect, or approve the images prior to any form of usage. I understand that the images may be modified to be used as design elements.

TREATMENT POLICY*

I hereby authorize PVC to render any treatment which is deemed critical to my pet's health while in their custody. I understand that in the event of any unforeseen or emergent circumstances, PVC will make every reasonable attempt to contact me or my agent before proceeding with treatment. I understand that I will be financially responsible for all emergency procedures including the Estimate of Treatment provided in person or via telephone.

PAYMENT POLICY*

All fees MUST be paid in full at the time services are performed or upon discharge from PVC. A deposit for expected treatment is required for all pets admitted to PVC. A late fee will be charged on all unpaid balances at a rate of 20% APR. Accounts will be turned over for collection if unpaid for more than 90 days. All costs of collection will be added to the outstanding balance.

NO-SHOW POLICY*

I hereby acknowledge when I schedule an appointment and fail to show, call or notify Pawsteps of my inability to keep this appointment time, it impacts their ability to provide services to both my pet and other clients. I understand fees will apply to my account if multiple appointments are missed without proper notification.

Please sign with your full name*