Date *

Are you a seasonal resident of Florida? *

Yes
No

Pet Information (Please give any of your pets prior records to the receptionist)

Pet's Name *

Sex *

Age/D.O.B *

Color *

Breed *

Previous Veterinarian(s): *

Reason for visit today *

Is this pet insured? *

Yes
No

Other pets in your household? *

Yes
No

Owner Information

Owner Name *

Spouse/Other Name:

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

I would like to be signed up for Vet2Pet & EpetHealth, the online portal and app that allows me to receive reminders, have access to my pets’ records, request appointments, request medication and prescription food refills, etc. I also would like to be sent a Trupanion 24 hour pet insurance offer (if my pet is eligible): *

Yes
No

How did you first hear of us? *

If referred to us by a specific client, who do we reward for this referral?: *

If referred to us by a groomer, who do we need to thank? *

If referred to us by another veterinarian, who do we need to thank? *

Informed Consent

I certify that I am at least 18 years of age or older and that I am legally and financially responsible for the treatment received at Companion Pet Care. I will assume responsibility for all charges incurred in the care of this pet. I understand that FULL PAYMENT IS DUE AT THE TIME SERVICE IS RENDERED and that a DEPOSIT IS REQUIRED FOR ANY HOSPITALIZED PET OR A PET THAT IS DROPPED OFF AT OUR CLINIC FOR ANY REASON.If full payment is not made as required, Companion Pet Care has my permission to obtain credit information from an authorized agency to assess my credit worthiness and/or to aid in collection. We accept credit/debit cards (Visa, Mastercard, AMX, Discover) and Care Credit

WE DO NOT ACCEPT CHECKS.

I grant Companion Pet Care the right to take photographs of me, my pet(s) and my property. I authorize them to copyright, use and publish the same in print and/or electronically. I agree that they may use such photographs of me with or without my name and for any lawful purpose including publicity, illustration, advertising and web content. *

Yes
No

I have read and understand the above statements and agree to all terms there in.

Yes

Signature *

Date *

LATE APPOINTMENT/CANCELLATION POLICY

We make every attempt to keep our appointments on time. In order to facilitate this, we strongly encourage you to show up 10 minutes prior to your appointment time. This allows for a smooth check-in process to update your pets’ medical records.

We do have a late fee* (7-14 minutes past your appointment time) for repetitve tardiness as follows:

1st time: Warning
2nd time: $10 late fee charged at the time of the appointment.
3rd time: $15 late fee and will be asked to pre-pay for any appointments at the time of scheduling.

If you arrive 15 minutes past your appointment time, we do ask to reschedule. If your pet is ill and needs immediate medical attention, your pet will be seen as a “walk-in/fit-in” appointment. You may have a much longer wait time than a scheduled appointment.

We ask for a 24-hour cancellation notice. We do have fees* for repetitve “No-Shows.”

1st time: Our staff ensures to call to make sure you and your pet are okay, offer a warning for any further “No-Shows.”
2nd time: $10 missed reservation fee
3rd time: $35 missed reservation fee and must pre-pay for future appointments at the time
of scheduling.

The staff here at Companion Pet Care thanks you for choosing us for your pets’ care and for your understanding of trying to meet each client’s needs in a timely fashion.

*These fees do not go to us for profit. They are given towards our Angel Fund to help those in need that do not have the financial means to care for their pet.

Signature *

Date *

New Client Form

New Client Form

Pet Information (Please give any of your pets prior records to the receptionist)

Owner Information

Informed Consent

WE DO NOT ACCEPT CHECKS.

LATE APPOINTMENT/CANCELLATION POLICY

Ready To Visit?

Questions?

Location

Contact Information

Hours