Client and Patient Form

Client and INITIAL PATIENT HISTORY FORM

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Date
MM slash DD slash YYYY
CLIENT INFORMATION:
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Preferred method of contact
Email*
Primary Contact Number*
Secondary Contact Number
Work Number:
How did you become aware of our practice?
Other
Have any of your other pets been examined by Dr. Samuel in the past?

PATIENT INFORMATION:
Pet's Name*
Name
Species:*
Other:
Breed:
Color:
Sex:
Spayed/Neutered?
Date of Birth:
MM slash DD slash YYYY
or Estimated Age:
Approximately how long have you had your pet?
How did you acquire him/her?
Vaccination history (including Rabies) Up to Date?
Can we give your pet treats?

Veterinary Clinic/Hospital Details:
Primary Care Veterinary Clinic/Hospital:
Primary Care Veterinarian Phone Number:
Primary Care Veterinary Name:
Other veterinarian(s) involved in your pet’s care:

Please review the following information
Your initials and signature at the bottom of this form indicate that you have read and agree to each of the policies listed
I authorize Ocean Veterinary Ophthalmology to take photographs and other documentations of my pet for educational and promotional purposes. All images, documents, videos, and other media will be altered to omit names and other identifying marks as to maintain confidentiality. I hereby grant consent for use of these documents without compensation and release Ocean Veterinary Ophthalmology from any and all claims arising from the use of these documents.*
I authorize Ocean Veterinary Ophthalmology to take photographs and other documentations of my pet for educational and promotional purposes. All images, documents, videos, and other media will be altered to omit names and other identifying marks as to maintain confidentiality. I hereby grant consent for use of these documents without compensation and release Ocean Veterinary Ophthalmology from any and all claims arising from the use of these documents.
Cancellation/Late Arrival Policy:*
Late Arrival/Cancellation Policy *: Arriving late for an appointment negatively impacts other clients’ schedule and OVO’s ability to stay on schedule. Late arrivals may experience significant wait times or may be required to reschedule, as clients arriving on time will be seen first. Cancellations of any appointment or procedures must occur 48 hours prior to the appointment. All missed appointments and appointments not cancelled in a timely fashion will be considered no-show appointments. After one no show appointment or after any single surgery/procedure not cancelled 48 hours prior to the scheduled appointment, clients will be required to leave a non-refundable deposit in order to schedule their next appointment or procedure.
I agree to the late arrival/cancellation policy. *
Prescription/Prescription Refill Policy*
Prescription Refill/Dispensed Medication Policy *: Patients must be examined annually to legally authorize refill requests. Prescription refills will be authorized based on the veterinarian’s discretion. Prescriptions filled at our practice may be picked up Monday, Tuesday, Thursday, Friday from 7:30 am-3:30 pm excluding holidays. We provide written prescriptions for your pet at no charge. ALL prescriptions including those filled at our clinic and external prescriptions (called in or faxed to a pharmacy) require 24-48 clinic hours to be completed. Prescription refills that need to be called in or faxed to a pharmacy are subject to a $15 charge. Per federal and state laws, any medications that have left the premises cannot be redispensed. We are unable to accept returns or issue refunds on any medication that has been taken out of the clinic.
I agree to the prescription refill/dispensed medication policy. *
Pick-Up Policy*
Pick-Up Policy*: Our office hours are 7:00 am-3:30 pm Monday, Tuesday, Thursday, and Friday. Ocean Veterinary Ophthalmology is not a boarding facility, therefore all patients left for procedures/surgeries or drop-off/emergency appointments must be picked up by the close of business the day of the procedure or appointment. On the day of your pet’s procedure or drop-off/emergency appointment, the doctor may arrange for your pet to be discharged after 3:30pm on a case-by-case basis. If your pet is not picked up by the close of business, we will transport your pet to the Emergency and Critical Care Department at The Life Centre in Leesburg, Virginia and additional fees may be incurred.
I agree to the pick-up policy
Treatment Policy:*
Treatment Policy *: By signing this form, the owner authorized the veterinarian to examine, treat, and/or prescribe medications for the animal described above.
I agree to the treatment policy. *
Payment Policy: **
Payment Policy *: The owner assumes responsibility for all charges incurred in the care of the animal described above. Payment is due in full when the animal is discharged. A deposit of two-thirds of the total estimated cost of any procedure/surgery may be required prior to treatment. OVO accepts payments by cash, check, Mastercard, Visa, Discover, American Express and Care Credit. Should this account default and is referred to an attorney for collection, the owner agrees to pay all collection costs, including attorney fees, up to 40% of the principal amount due and owing when turned over for collection. Returned checks will be assessed a $30 NSF fee in addition to the original face value of the check. This fee is separate from any bank charges incurred.
I agree to the payment policy. *
Are you planning on paying by check?*
If YES, please provide the following information:
Driver’s License #:
State:
Date of Birth:
MM slash DD slash YYYY
Thank you for choosing Ocean Veterinary Ophthalmology for the care of your beloved pet!

Client and INITIAL PATIENT HISTORY FORM

Client and Patient Form

Step 1 of 5

CLIENT INFORMATION:

PATIENT INFORMATION:

Veterinary Clinic/Hospital Details:

INITIAL PATIENT HISTORY FORM

Please review the following information

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