New Client Intake FOrm

In case of Emergency, if different than the above name please complete this section:

Other Person(s) Authorized to Give Consent for Surgery or Treatment:

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 understand that GVH is not staffed 24 hours per day and the continuous presence of qualified personnel may not be provided. I hereby authorize this hospital to receive, prescribe for, treat or perform surgery upon the pet(s) I’m listing and any additional pets I/we present in the future. I understand that it is my/our responsibility to keep all account information (including, but not limited to: address, phone, email and all other owner information under this household) current with GoldenView Veterinary Hospital.

I agree to pay the fees for all services rendered at the time my pet/s are discharged from the hospital and agree to pay for the costs of collection/check fees and/or legal action/court costs in the event that collection efforts become necessary. I have read and signed the GVH Financial Policy. If I neglect to pick up my pet within 5 days of the discharge date and do not notify you within that time period, GVH is to assume that the pet is abandoned and I hereby authorize GVH to assume legal accountability for the disposition of said abandoned animal.

DUE TO STATE LAW AND INSURANCE REQUIREMENTS, ALL DOGS MUST BE CURRENT ON RABIES VACCINATION. WE STRONGLY ENCOURGE CURRENT RABIES VACCINATIONS FOR ALL CATS AND FERRETS AS WELL. To help prevent the spread of infectious diseases, all hospitalized and boarded animals must be current on all vaccinations and the required annual testing. Vaccinations may be updated at the time of your appointment if not current.

Thank you for choosing GVH for your pet’s veterinary care. Our practice will offer you and your pet state of the art medical and surgical care, assist you in maintaining your pet’s wellness, and provide a variety of ancillary services to you and your pet.

Of course, the services that we provide do come with an associated cost. We hope that financial considerations will not be an obstacle to offering the best level of care to your non-human family member. We are always available to answer your questions and to assist you in any way that we can. The information in this form is to further communicate to you the variety of payment options we offer to ensure that the cost of care is not a barrier to the quality of care.

For you and your pet’s benefit:

• We believe that you, our client, would like to know and understand our financial guidelines in advance of your pets’ treatment.
• We believe in the value of clear communication as well as mutual understanding and respect.
• We suggest that you purchase pet insurance for all eligible or insurable pets.
• A Diagnostic/Treatment Plan (or estimate) may be provided prior to providing services and will always be provided to you upon request.
• We are happy to discuss the Diagnostic/Treatment Plan and our practice guidelines with you at anytime.
• For pets who are hospitalized, we will request a deposit of at least 50% of the Diagnostic/Treatment Plan at the time of admission.
• We will update you daily on both your pet’s clinical condition and the status of your account.
• We require payment in full at the time services are rendered or, if hospitalized, at the time of discharge/pick up.
• We accept the following forms of payment: Cash, MasterCard, Visa, Discover, American Express and Care Credit (ask us for more information if you have not heard of Care Credit)