New Client Registration?Form
Download
Surgery Consent Form
Download

New Client Registration Form

Thank you for choosing Hoegemeyer Animal Clinic. We want to know our clients and patients. Please take a moment to fill out the information below. Thank you!

REGISTRATION

*Owner:

Spouse's Name:

*Address:

City / State:

State:

Zip:

*Phone:

Cell Phone:

Business Phone:

*E-mail:

Employer:

Spouse Employer:

DL#:

Emergency Contact:

Emergency Contact Number:

How Did You Hear About Us?

GoogleFacebookYelpDrove By/Saw Sign

Humane Society/Rescue Group – If so, who?

HAC Team Member – If so, who?

HAC Client – If so, who?

AUTHORIZATION / CREDIT POLICY

I hereby authorize the veterinarian to examine, prescribe for, or treat the above pet. I assume all responsibility for all charges incurred in the care of this animal. Payment is due when services are rendered. In some cases, an advance deposit may be required. You may pay cash, personal check (with proper ID), Visa, Mastercard, Discover or American Express. To avoid misunderstandings, we urge fees be discussed with the doctor before services are performed. $15.00 service charge on returned checks.

*Signature:

*Date:

SURGERY CONSENT FORM

*Owner's Name:

*Patient's Name:

Date:

Your pet is scheduled for anesthesia/surgery.

Our objective is to provide the very best in patient care. We recommend a pre-anesthetic blood work for all anesthetic procedures, Our in-house lab enables us to perform these tests BEFORE your pet is placed under anesthesia. For our older patients, the testing includes screening for kidney disease, liver disease, and diabetes. These conditions, as well as anemia, infection, and dehydration can all be detected and addressed prior to anesthesia. If we detect abnormalities in our testing, your pet’s procedure will be delayed and you will be
notiﬁed of the problem.

*Please note any previous medical conditions you are aware of this pet.

Please check the following:

ACCEPT - I accept pre-anesthetic blood work testing for my pet.DECLINE - I decline pre-anesthetic blood work testing for my pet.

COST $92.40

Please check the following:

ACCEPT - I accept pain control injection for my pet.DECLINE - I decline pain control injection for my pet.

COST $38.47

Please check the following:

ACCEPT - I accept a pre-anesthetic E.K.G and use of a pulse oximeter for my pet.DECLINE - I decline a pre-anesthetic E.K.G and use of a pulse oximeter for my pet.

COST $23.29

Please check the following:

ACCEPT - I accept the placement of an IV Catheter.DECLINE - I decline the placement of an IV Catheter.

COST $48.69

Please check the following:

ACCEPT - I accept having my pet given a microchip.DECLINE - I decline having my pet given a microchip.

I have read and acknowledge consent for the above-accepted procedures to be performed and understand additional charges apply and are not combined with anesthesia/surgery.

*E-Signature:

*Day Phone Number