Client Information Form | Mill Pond Veterinary Clinic

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Client Information Form

Name:

Email:

Phone:

Spouse/Other:

Street Address:

City:

State:

Zip Code:

Primary Phone

Phone is:

Alternate Phone Number:

Alternate Phone is:

Emergency Contact and Phone:

Driver's License Number:

Employer's Name and Address:

Payment Information - ensuring that our patients receive high quality care is the goal of our practice. To help us to be able to perform such care, payment is due at the time of treatment. We accept cash, check and major credit cards (Discover, Mastercard, Visa, Amex). Please indicate below , your preferred form of payment to settle your account:

Check or cash

Major Credit Card

Signature (type name):

Date:

How did you hear about our practice?

If referred to our practice, please provide who referred you:

Who is your current veterinarian/clinic?

What has caused you to seek services elsewhere?

What is the most important factor for you in choosing a veterinary relationship?

Free Text

What services are you planning to use at our facility? We will send you information on the services you indicate.

Veterinary/Medical

Yes

Boarding

Yes

Daycare

Yes

Small Animal Rehab

Yes

Chiropractic

Yes

Canine Obedience Training

Yes

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The following are our guidelines for accepting new clients and new patients. Please be sure to complete the Pet Information sections below our guidelines.

We will encourage our clients to make use of our Daycare, Boarding, and Training services. We feel that this helps make a well-rounded pet. This also makes the patient experience in our Hospital a more positive one.

We expect our clients to be a partner in the medical and behavioral decisions for their pets.

We expect our clients to have their pets in to our facility yearly for their annual exams and maintenance vaccinations/bloodwork/preventatives.

We expect our clients to use heartworm, flea and tick preventatives.

We expect our clients to understand the importance of training, development, and socialization, particularly at early stages of a pet's life.

We expect that if the Doctors or Staff recommend starting a training program in order to prevent behavioral issues that our clients will be willing to proceed with these services for their pet.

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We expect that all prior veterinary records will be emailed to our office and that new client paperwork will be filled out through our web portal at least 48 hours prior to the scheduled appointment.

We expect that all clients will practice the "Golden Rule" of treating our staff with the same kindness and courtesy that they would expect to receive themselves.

Medicine is not a perfect science. We strive to work as a team with you, the client, to help you make the best, informed decisions for your pet and family. We understand tose decisions may vary depending on the many factors that you have to consider.

Thank you .

The Staff at Mill Pond Veterinary Clinic & Camp Mill Pond

Patient Name:

Date of Birth/age:

Species:

Breed:

Color:

Gender:

Male

Female

Spayed/Neutered:

Yes

Normal Attitude:

Pet Origin (ie breeder/resue):

Length of time owned:

Diet (type and amount):

Rabies Vaccine Date:

Distemper Vaccine Combo (DHLPP/FVRCP)

Other:

Heartworm or Leukemia Test Date and Results:

Prior illness or surgery:

Thank you for contacting us.
We will get back to you as soon as possible.

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Patient #2

Your Name:

Email:

Patient #2 Name:

Patient #2 Date of Birth/age:

Patient #2 Species:

Patient #2 Breed:

Patient #2 Color:

Patient #2 Gender:

Male

Female

Patient #2 Spayed/Neutered:

Yes

Patient #2 Normal Attitude:

Patient #2 Pet Origin (ie breeder/resue):

Patient #2 Length of time owned:

Patient #2 Diet (type and amount):

Patient #2 Rabies Vaccine Date:

Patient #2 Distemper Vaccine Combo (DHLPP/FVRCP)

Patient #2 Other:

Patient #2 Heartworm or Leukemia Test Date and Results:

Patient #2 Prior illness or surgery:

Thank you for contacting us.
We will get back to you as soon as possible.

Oops, there was an error sending your message.
Please try again later.

Patient #3

Your Name:

Email:

Patient #3 Name:

Patient #3 Date of Birth/age:

Patient #3 Species:

Patient #3 Breed:

Patient #3 Color:

Patient #3 Gender:

Male

Female

Patient #3 Spayed/Neutered:

Yes

Patient #3 Normal Attitude:

Patient #3 Pet Origin (ie breeder/resue):

Patient #3 Length of time owned:

Patient #3 Diet (type and amount):

Patient #3 Rabies Vaccine Date:

Patient #3 Distemper Vaccine Combo (DHLPP/FVRCP)

Patient #3 Other:

Patient #3 Heartworm or Leukemia Test Date and Results:

Patient #3 Prior illness or surgery:

Thank you for contacting us.
We will get back to you as soon as possible.

Oops, there was an error sending your message.
Please try again later.

Mill Pond Veterinary Clinic provides veterinary services, small animal rehabilitation, doggie daycare,

dog and cat boarding and dog training for Quakertown, Coopersburg, Center Valley, Pennsburg and surrounding towns.

All prices subject to change without notice.

Mill Pond Veterinary Clinic

Phone: 215.536.4443
2255 Mill Pond Road, Quakertown, PA 18951

Office Hours: Monday 8:00AM-7:00PM

Tuesday-Friday 8:00AM-6:00pm

Saturday 8:00AM-1:00pm