Owner's Information

Owner Name *

First

Last

Co-Owner Name

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Please list any phone numbers that you would like the clinic to call, text and/or to leave a message.

Owner's Phone

Home Phone Number

Cell Phone Number

Work Phone Number

Co-Owner's Phone

Home Phone Number

Cell Phone Number

Work Phone Number

In case of your absence, is there anyone other than the above-mentioned who may authorize treatment of your pet(s)?

Name

First

Last

Phone Number

Please enter a valid phone number.

Phone Type

Owner's Email Address *

(To receive copies of lab work, appointment reminders, and other client/patient communications.)

Who is your preferred Doctor? *

Dr. Paula Foland
Dr. Ron Foland
No Preference

What is your preferred form of communication?

Telephone
Text Message
Email

How did you become aware of our clinic?

Personal Recommendation - Whom may we thank for your referral?

Pet's Information

Pet's Name

Species

Dog
Cat

Age/Date of Birth

Breed

Sex

Male
Female

Color/Markings

Spayed/Neutered

Yes
No

Do you have a second pet? *

Yes
No

Pet's Name

Species

Dog
Cat

Age/Date of Birth

Breed

Sex

Male
Female

Color/Markings

Spayed/Neutered

Yes
No

Do you have a third pet?

Yes
No

Pet's Name

Species

Dog
Cat

Age/Date of Birth

Breed

Sex

Male
Female

Color/Markings

Spayed/Neutered

Yes
No

Do you have a fourth pet?

Yes
No

Pet's Name

Species

Dog
Cat

Age/Date of Birth

Breed

Sex

Male
Female

Color/Markings

Spayed/Neutered

Yes
No

Do you have a fifth pet?

Yes
No

Pet's Name

Species

Dog
Cat

Age/Date of Birth

Breed

Sex

Male
Female

Color/Markings

Spayed/Neutered

Yes
No

Do you have a sixth pet?

Yes
No

Pet's Name

Species

Dog
Cat

Age/Date of Birth

Breed

Sex

Male
Female

Color/Markings

Spayed/Neutered

Yes
No

Name of Previous Clinic

Phone Number

I grant Foland Veterinary Services permission to post my pet's picture, story, or medical information in print and/or on our social media?

Yes
No

To serve you better, please let us know:

Is there anything you would like for us to know about your pet(s)? Any major surgeries or illness?

What is most important to you in veterinary care?

Permission to Treat: I, the undersigned owner or Good Samaritan, hereby take responsibility for seeking veterinary care of the above described pet(s) and any other pet(s) presented by me in the future. I certify that *

I am
I am not

over eighteen years of age, to be able to consent to authorization for a veterinarian of Foland Veterinary Services, PLLC to examine, prescribe medications for, treat, board, hospitalize, sedate, anesthetize, and/or perform surgery to the above-described pet(s) and any other pet(s) presented by me in the future.

In the Case of a Potential Abandonment, an authorized agent of mine or I will pick up the above-described pet(s) and pay for all accrued charges within five days of receiving a written or oral notification that my pet(s) are in danger of being considered abandoned after I was notified that my pet(s) are ready to be released from our clinic. If a written notice is required, it will be given at the address maintained on the clinic’s client/patient record. I agree that if I fail to comply with this policy, this practice may handle this abandonment in the best interest of my pet(s) and the clinic, and I will be responsible for all fees incurred.

Guarantee of Payment: I, the undersigned owner or Good Samaritan, assume responsibility for all charges incurred by the board/care of my pet(s). I understand and promise to pay Foland Veterinary Services, PLLC, for all charges and expenses incurred in the board/care of my pet(s). I also understand that these charges will be paid in full at the time my pet(s) are released back into my care, and that a deposit may be required for hospitalized and/or surgical treatment. Foland Veterinary Services, PLLC requires full payment at the time that services are rendered. All accounts that are not paid as agreed upon are considered delinquent. Delinquent accounts will be sent to a collection agency, and the account will be charged an additional $50.00 service/handling fee, plus any legal fees incurred in the collection of this debt.

Payment is due when services are rendered. For your convenience, we accept cash, Discover, Visa, American Express, MasterCard, CareCredit, and ScratchPay

If you are interested, ask one of our team members for information on how to apply for CareCredit or ScratchPay.

Date *

Signature *

Clear Signature

Thank you for your confidence in Foland Veterinary Services. We appreciate the opportunity to serve you!

New Client Form

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Owner's Information

Owner's Phone

Co-Owner's Phone

Pet's Information

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