New Client Form

Name
First Last
Spouse's Name
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone Number
Cell Phone Number
Spouse's Phone Number
Is this a cell phone?
- Yes
- No
Primary email

(Your email address will NOT be sold.)
I consent to the use of periodic appointment reminder phone calls, voice mail messages, postcards, email or letters.
- Yes
- No
Preferred method of contact
- Email
- Postal Mail
Emergency contact
Phone
Previous Veterinarian or clinic
I request release of all pertinent care records to Buckeye Veterinary Clinic.
- Yes
- No
How did you hear about us?
- Driving by
- Online Search
- Phone Book
- Newspaper/Video Ad
- Friend or Family that introduced us
Name
Patient Information
Name
Birthdate/Age
Please Choose
- Dog
- Cat
Breed
Coat Color
Please Choose
- Male
- Female
Is your pet spayed or neutered?
- Yes
- No
- Unknown
Hospital Policies
We thank you for allowing us to take care of your pet. In order to provide the best possible animal care, we require that all professional fees are due at the time services are rendered. We accept several payment options. They include cash, personal checks, debit cards, as well as credit cards. There has to be a $30.00 or 10% (whichever is greater) service charge for any check returned unpaid. Care Credit payment plan: A receptionist will be happy to discuss this monthly payment plan with you. Approval from Care Credit is required. We routinely provide written estimates. Critical patients that need extended hospitalization will have the balance updated daily. We are glad to work with you and give multiple estimates in order to help us provide medical care that your pet may need. In the end, we always want what is best for you and your best friend.
Client agreement
I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that prior to treatment, a full explanation of the procedure(s) involved will be given by the veterinarian (and/or staff) in the care of my animal(s). I agree to pay for all services rendered by this office. I also understand that should my account become delinquent, my information may be released to a third party collection agency to assist with collecting fees associated with treatment rendered by this office.
Photo Consent
I hereby grant full permission to Buckeye Veterinary Clinic, LLC to use either my photograph and name (if necessary) or my pet’s photograph and name (if necessary) in any publication or advertising materials (printed or electronic). This consent also serves to waive all rights of privacy or compensation which I may have in connection with the use of my photograph and/or name or my pet’s photograph and/or name.
Signature
Date
Date Format: MM slash DD slash YYYY

Patient Information

Hospital Policies

Client agreement

Photo Consent

CONTACT INFORMATION

HOURS OF OPERATION

OUR LOCATION