New Patient Form – Buttercup Veterinary Hospital Cedar Park, Texas

Please arrive 10 minutes before your appointment time.

Date of your appointment*

This helps us to make sure we have all your information correct before your appointment.

Owners first and last name:*

Are you:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Home Phone*

Cell Phone*

Work Phone*

How did you hear about us?

Referral
Our website
Sign
Internet
Coupon
Magazine

If it was a referral, we would like to thank them.

Let us know who we can send a Thank You card too.

Number of dogs in your household

Number of cats in your household

Other pets in household?

Reason for visit.*

Give a brief description of your pets needs today.

I Hereby authorize the veterinarians of BVH to examine, prescribe for, and/or treat the described pet(s). I assume all financial responsibility for charges incurred in the care of my pet(s). I understand that all charges must be paid, in full, at the time of release. BVH accepts cash, credit card, Care Credit or Wells Fargo Financial for new clients. At any point BVH may request a deposit for treatment services while my pet(s) are in the care of BVH. By signing this document I agree and authorized all of the above and will allow BVH to release my pet(s) records to other hospitals and/or specialist as needed.

Appointment Policy

At BVH, we put our faith in you to keep your appointment. When we set up an appointment, a specific amount of time is reserved especially for you and your pet.
If for any reason you must cancel or change your appointment, it is important that you give our office at least 24 hours notice so that we may offer that appointment to someone else.

Late arrival: When we reserve time for you and your pet, we require all of that time to provide you with the best quality care possible. When you are late it decreases our ability to accomplish this and to meet the needs of those who are on time for their scheduled visit. For this reason we ask that you and your pet arrive 10 minutes prior to your scheduled appointment. Should you arrive later than the scheduled appointment then we will be rescheduling your appointment or seeing our pre-scheduled patients first.

Missed appointment: If an appointment is missed or canceled within the 24 hour window it will be considered a missed appointment. We will allow 2 missed appointments before we will require a pre-paid exam fee to schedule any future appointments with our doctors. Upon arrival and completion of the appointment, the deposit will be credited towards the invoice of the visit. If the appointment is missed then the entire deposit is non-refundable.

Surgery: A deposit fee is required at the time of scheduling your pet's surgery. The deposit will be credited towards the invoice on the day of the procedure. This deposit is refundable only if canceled 7 business days prior to the procedure. Any cancellation after this allotted time will result in the loss of the entire deposit.

Boarding: During major holidays a deposit is required, per pet, at the time of scheduling your pet(s) boarding. The deposit will be credited towards the invoice at the time of check out. This deposit is refundable only if canceled 2 business days prior to the boarding reservation. Any cancellation after the allotted time will result in the loss of the entire deposit.

By signing below you agree that you have read, understand and will abide by all of BVH terms and conditions.

Authorized Signature*

Do you have copies or access to your pets past records?*

Yes
No

Please provide name and number of clinic.*

If you do not know the phone number please provide as much information so we can do internet research. If your pet doesn't have a medical history, type N/A.

Pet's name.*

What type of pet?*

Dog
Cat
Other

If not listed select 'other' and fill in.

Other Type of pet

Gender*

Male
Neutered male
Female
Spayed female

Breed*

If not sure of breed use "Mixed" If cat use DSH (Domestic Short Hair), DMH or DLH.

Birthdate*

Color*

Please check all presenting problems you have noticed with your pet.*

If other please explain.

If your pet is on any medications, please list.*

Column 1	Column 2	Column 3

If you need to list more than 3 items, click on the "+" to add. Please list the brand, if your pet is on monthly Heartworm and/or flea prevention.

Reactions or allergies to vaccines or medications?*

Vaccine allergies
Reactions to medications
No

If yes to one or both of the above please explain.

Describe your pet's diet.*

Type of food (dry/wet/combo of both). How often fed in a day and amount.

Do you have more than one pet we will be seeing today?*

Yes
No

Pet's name.*

What type of pet?*

Dog
Cat

If not listed select 'other' and fill in.

Gender*

Male
Neutered male
Female
Spayed female

Breed*

If not sure of breed use "Mixed" If cat use DSH (Domestic Short Hair), DMH or DLH.

Birthdate*

Color*

Do you copies or access to your pets past records?*

Yes
No

If no, please provide name and/or number of clinic we can call.*

If you do have records type in "Have records"

Please check all presenting problems you have noticed with your pet.*

If your pet is on any medications, please list.*

Column 1	Column 2	Column 3

If you need to list more than 3 items, click on the "+" to add. List if your pet is on monthly Heartworm and/or flea prevention.

If other please explain.

Reactions or allergies to vaccines or medications?*

Vaccine allergies
Reactions to medications
No

If yes to one or both of the above please explain.

Describe your pet's diet.*

Type of food (dry/wet/combo of both)

BVH New Patient Form

Please arrive 10 minutes before your appointment time.

Appointment Policy

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