New Client Form Client InformationThank you for selecting HomeVets for your pet’s health care needs. Please help us create an accurate record for you and your pet by completing the following informationName First Last Cell Contact(Required)Secondary Contact(Required)Alternate Contact(Required)Email(Required) Physical Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your mailing address the same as your physical address?(Required) Yes No Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCĂ´te d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRĂ©unionSaint BarthĂ©lemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTĂĽrkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweĂ…land Islands Country Pet InformationPet’s Name(Required)Species(Required)Breed(Required)Sex(Required) Male Female Altered(Required) Yes No Color(Required)Date of Birth/Age(Required)Previous Vet/Contact(Required)Microchip #(Required)Temperament (describe)(Required)Diet(Required)Medications (dose/frequency)(Required)Flea, Tick, Heartworm prevention(Required)Known reactions to drugs or vaccines(Required)Major Medical issues(Required)Prior Surgeries(Required)Medical Issues/Diagnoses(Required)Do we have permission to use your pet’s picture(s) for learning, marketing, or online/social media purposes?(Required) Yes No Do we have permission to communicate with you via cell phone, home phone, email, and USPS mail?(Required) Yes No Do you have Pet Insurance for any of the pets listed?(Required) Yes No Provider(Required)Policy Number(Required)Do you want to add another pet ?(Required) Yes No Second Pet InformationPet’s Name(Required)Species(Required)Breed(Required)Sex(Required) Male Female Altered(Required) Yes No Color(Required)Date of Birth/Age(Required)Previous Vet/Contact(Required)Microchip #(Required)Temperament (describe)(Required)Diet(Required)Medications (dose/frequency)(Required)Flea, Tick, Heartworm prevention(Required)Known reactions to drugs or vaccines(Required)Major Medical issues(Required)Prior Surgeries(Required)Medical Issues/Diagnoses(Required)Do we have permission to use your pet’s picture(s) for learning, marketing, or online/social media purposes?(Required) Yes No Do we have permission to communicate with you via cell phone, home phone, email, text, and UPSP mail?(Required) Yes No Do you have Pet Insurance for any of the pets listed?(Required) Yes No Provider(Required)Policy #(Required)Do you prefer in-home, in-office, or no preference(Required) In-home In-Office No Preference How did you hear about us?(Required) Through a friend Emloyee You are a legacy PVVH Client Affiliation/Family Internet Other Other(Required)Disclosure Professional fees are to be paid at the time services are rendered. Forms of payment include cash, Mastercard, VISA, AmEx, Discover, text-to-pay, email-to-pay, or a secure link. We do not accept prepayments for items, with the exception of deposits. We do not carry open accounts or offer payment plans of any kind at this time. We can provide you with a printed/emailed estimate, upon request, before any services are rendered. We do require a 24-hour notice to adjust or cancel your appointment. There will be a $50 cancellation/no-show fee will be placed on your account if you do not provide appropriate notice or fail to show up for your appointment. We do require a 48-hour notice to adjust or cancel your surgery or drop-off procedure. There will be a $250 cancellation/no-show fee will be placed on your account if you do not provide appropriate notice or fail to show up for the surgery or drop-off procedure. By signing below, you agree to the foregoing terms of payments, deposits, and company policies. You are acknowledging that anyone who is accompanying your pet in your place is authorized to approve treatment plans and will provide a form of payment at the time of service. Owner Signature (18 +years of age)(Required)Printed Name(Required)Date(Required) MM slash DD slash YYYY CAPTCHA Δ
