New Patient Information

Patient's Name *

Client / Owner Information

Name *

First

Last

Primary Phone Number *

I consent to receive SMS text messages from Valley Veterinary Hospital. Msg & data rates may apply. Reply STOP to opt-out. *

Yes
No

Secondary Phone Number

Email *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date / Time

Occupation

Spouse / Co-Owner Information

Name

First

Last

Spouse / Co-Owner Information

Primary Phone Number

Secondary Phone Number

Email

Pet Information

Pet Name

Pet Type

Cat
Dog
Other

If Other, please specify:

Pet Breed

Pet Color

Pet Sex

Male
Male Neutered
Female
Female Spayed

Pet Date of Birth / Age

Please list any hospitals or clinics that you have brought your pet to previously. *

Do you have another pet to add to your account?

Yes
No

Secondary Pet Information

Pet Name

Pet Type

Cat
Dog
Other

If Other, please specify:

Pet Breed

Pet Color

Pet Sex

Male
Male Neutered
Female
Female Spayed

Pet Date of Birth / Age

Cancellation Policy

We will now be collecting deposits according to the following schedule:

Appointment Type	Deposit Amount
Saturday Appointment	$50
Same-Day Appointment	$50
Surgery/Dental Procedures	$100*
Ultrasound/Echocardiograms	$100*
TPLO/Orthopedic Surgeries	$250**

*Surgery, dental, ultrasound, and echocardiogram appointments that are canceled within 72 hours or are not shown up for will forfeit their deposit.
**TPLO/orthopedic surgeries are non-refundable

We will also be implementing cancellation fees according to the following schedule:

Appointment Type	Cancellation Window	Fee
Sick/Wellness Appointment	If canceled within 24 hours	$50 or forfeit of any deposit
Technician Appointment	If canceled within 24 hours	$20
Surgery/ Dentals/ Ultrasounds/ Echocardiograms	If canceled within 72 hours	$100 or forfeit of any deposit
TPLO/Orthopedic Surgeries	N/A	Forfeiture of $250 deposit

I have read the above cancellation policy and understand I am responsible for any fees associated with making my appointment or not canceling my appointment in the appropriate amount if time. *

I have read and understand

I hereby authorize the veterinarian to examine, prescribe for or treat the above-described pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges must be paid in full, at the time of release of the pet. *

I authorize

Signature

New Milford New Patient Information

Client / Owner Information

Spouse / Co-Owner Information

Pet Information

Secondary Pet Information

Cancellation Policy

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Valley Veterinary Hospital