New Client Form Owner First Last Mailing AddressNumberStreetApartment NoCityStateZip CodeHome PhoneEmployerWork PhoneCell PhoneState/DL NoEmail AddressSpouse or Co-OwnerHome PhoneWork PhoneCell PhoneHow did you hear about us?Drive ByFriendInternetYellow PagesWelcome WagonIf referral was by a friend, please list their nameHow would you like to be reminded of future recommended preventative health care services for your pet?PhoneEmailPet InformationPET #1NameCat, Dog, or OtherBreedColorBirthdate or AgeSexSpayed or NeuteredPET #2NameCat, Dog, or OtherBreedColorBirthdate or AgeSexSpayed or NeuteredName of Previous/Current VeterinarianPhone**To prevent the spread of diseases and parasites, we recommend animals be current on all vaccines. Pets with fleas will be treated with a topical or oral flea medication on admission, and the prescription price will be included in the invoice**I understand every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care and handling. I hereby authorize this hospital to receive, prescribe for, treat or perform surgery upon the pet(s) listed on the reverse side and additional pets I present, Furthermore, I agree to pay fees for services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated. I agree to pay for the reasonable costs of collection in the event that collection efforts become necessary. I understand that a service fee of $31.00 will be assessed for each non-sufficient fund check and/or certified letter that must be sent. Continuous presence of qualified personnel may not be provided. If I neglect to pick up my pet within 5 days of the discharge date and do not notify the hospital within that time period, we will assume that your pet gas been abandoned and you have therefore relinquished ownership of your pet to Hardin Valley Animal Hospital.May we post your pet's photo online (ie facebook)?YesNo**We MUST have new patient records arrive to us BEFORE scheduled appointment.**File Upload Drop files here or SignatureDateHVAH Policy For Pets Requiring Special Handling We at Hardin Valley Animal Hospital (HVAH) take our Fear Free Policies and procedures seriously. We aim to prevent increasing our animal patient's fear, anxiety and stress (FAS) during their visit with us. To aid in preventing FAS, we adhere to our policy that outlines our company goals and aspirations for a positive outcome for aggressive, fearful or anxious pets. When an aggressive animal is presented that requires treatment and handling, HVAH, LLC reserves the right to decline services to this pet. Any aggressive or unmanageable animal presented to our hospital may be refused services. This decision will be determined by the veterinarian.If a muzzle has been suggested by or required by a veterinarian previously or at the time of presentation, a muzzle must be placed and properly secured by the owner before entering our hospital (Basket muzzle is recommended).If the patient is not muzzled as requested, muzzle is not of appropriate size, is not secure or is removed by the owner before being asked to do so, treatment or examination of said pet may be denied.An aggressive animal may require an oral sedative for examination or treatment. If oral sedatives do not provide the desired outcome to provide patient care in a safe manner for staff and patient, injectable sedation will be required for further examination and/or treatment.Any incident of aggressive behavior shown during an examination or treatment provided by HVAH, LLC staff, will be documented in the animals record and all appropriate precautions will be taken by the veterinarian and staff treating the patient from that point forward.If one of our veterinarians recommended and prescribed pre-visit medication to decrease the patient's fear, anxiety and stress, the owner must comply with these instructions and give the medication as directed. It the owner does not comply with this plan, the patient will not be seen that day and will be required to reschedule their appointment following the proper pre-visit medication protocol. Despite all efforts to create a positive outcome for each visit, we cannot guarantee your pet will receive the necessary treatments needed or required. We value being able to provide quality patient care and adhering to Fear Free Practice standards to ensure we are ethically creating the best experience for our patients, owners and hospital staff. By being a Fear Free Practice, we stand by our guidelines and enforce our policies fully. You as our valued clients will assist in creating positive outcomes for each visit by following our guidelines and complying with the veterinarian's instructions. By signing below, you understand that HVAH, LLC expects proper scheduling, medicating upon request, and owner compliance to assist in being able to properly evaluate your pet.SignatureDate Date Format: MM slash DD slash YYYY Fear Free QuestionnaireAs fear free certified professionals, we want to make your visit to our hospital the best it can be for you and your pet. If you have a few minutes, I’d like to ask you a few questions so we can take both your and your pet’s preferences for your first visit to our hospital into consideration.How would you describe your pet’s reaction to going to the veterinary hospital?Eager/ExcitedSubduedReluctantSomewhere in betweenAre there things you or your pet did not like during past veterinary visits?Being weighedGetting on the exam tableHave a procedure doneBeing handled by the staffWalking into the clinicHow would you describe your pet around other animals and people, such as in the lobby?Does your pet preferFemale veterinary professionalMale veterinary professionalDoesnt matterWhat are your pet’s favorite treats? (Suggest they bring some to the visit)Does your pet like to play with toys? If so what kind? (Suggest they bring their favorite toy in)Has your pet been prescribed any medication to help with a visit to the veterinary hospital? If so, what medications were used and did they help alleviate stress and anxiety for your pet?A successful Fear Free visit starts at home and continues during your travel to our hospital. To help provide your pet with a pleasant experience on the way to the hospital, we can send you some preparations tips via email. However, I have a few questions regarding travel to see if we need to make any special recommendations.How and where does your pet travel in the car?CarrierSeatbeltLooseDoes your pet show any reluctance to getting in the carrier or the car?YesNoHow does your pet behave in the car?VocalBarkingWhiningRestlessPacingPantingDroolingTremblingHidingDoes great / no issuesAny nausea, drooling or vomiting with car travels?YesNo
