New Clients Form-Barn

New Clients Form

At Barn & Home Veterinary Clinic we see dogs, cats, cattle, goats, sheep, llamas, alpacas, pigs, chickens, ducks, turkeys, geese and more. We do NOT see horses, donkeys, mules, exotics, or wild animals. We are scheduling basic appointments (herd health, well pets), non-routine appointments (sick or injured animals), and surgery. Once you have submitted the New Client Form, if there are records to request we will do so. Once we have records for your animal(s) we will contact you. If you have a herd or flock of animals, feel free to simply call them ‘Herd’, ‘Flock’ or other encompassing term where it asks for an animal name in the form below. If you have more than three animals, we will be able to enter their information later.

First Name

Last Name

How did you hear about us?

Website

Facebook

Instagram

Referral

Phone Number

Address

Is GPS accurate? Any special directions/tips to ensure we arrive at the correct location?

How do you prefer we contact you?

Phone - call

Phone - texting

NOTE Regarding Communication Preference

Due to being purely mobile, we prefer texting - we have limited staff and are in back-to-back appointments, plus often in areas with no cell service (our only option is texting). Texting is generally the fastest and easiest way for us to contact you. If you prefer a phone call, we may try texting first - we will still work towards calling, but it may take longer for us to get back to you. Please bear with us as we do our best to get everyone taken care of.

Animal 1 Name:

Animal 1 Species:

Animal 1 Breed:

Animal 1 Color:

Animal 1 Age or Birthdate:

Animal 1 Gender:

Animal 1 Previous Vet Records are at:

Animal 2 Name:

Animal 2 Species:

Animal 2 Breed:

Animal 2 Color:

Animal 2 Age or Birthdate:

Animal 2 Gender:

Animal 2 Previous Vet Records are at:

Animal 3 Name:

Animal 3 Species:

Animal 3 Breed:

Animal 3 Color:

Animal 3 Age or Birthdate:

Animal 3 Gender:

Animal 3 Previous Vet Records are at:

What are your needs – urgent and/or non-urgent? PLEASE put at least a short description of your current needs.

Payment

All fees are due at time of service. We accept checks, cash and cards. If payment is not completed at the end of the appointment, there will be a $50 late payment fee and $3/day for each additional day that the invoice goes unpaid. The only exception is if there is prior authorization for the payment to be made at a later time. If the appointment is canceled in less than 24 business-day hours there will be a cancellation fee. We are happy to give you an estimate prior to scheduling.

I certify that I acknowledge, understand and will be prepared financially for payment due at time of service.

Please Be Ready

Since we are coming to your home or barn, we require you to have any and all animals ready when we arrive. If this is livestock, please have them in a pen ready to be moved through the chute or worked with. If this is a cat, we recommend keeping them in a small room or bathroom starting at least 30 minutes prior to their appointment. Likewise for other animals – ensure they are ready at their appointment time. If it takes longer than 10 minutes to catch/get an animal ready, we may have to leave for our next appointment and the mileage and exam fees are forfeited. We do also charge for our time - if we have enough time to stay while the animal(s) are found/restrained, we do charge from the time we arrive to the time the appointment is finished - regardless of time spent providing the scheduled services.

Authorized Agent: We ask that whomever is presenting the animal at the appointment know the animal(s), be able to answer any and all questions regarding history/symptoms/etc., be able and willing to make both medical and financial decisions for the animal(s), and have payment ready. We will not complete services we do not have authorization for. If you (the owner of the animal(s)) is not able to be present, we request to be informed of the individual that will be present prior to the appointment. We request at minimum the person’s name, phone number and a statement from you that the person is authorized to make medical and financial decisions.

I certify that I acknowledge, understand that my animal(s) need to be ready at the time of the appointment. Failure to have them ready may result in extra charges for time or needing to reschedule with the mileage and exam fees forfeited.

Damages

Due to the nature of our business, we will be coming into your home, barn and/or garage. If any damages to your home, barn, garage, property or personal items occur due to the behavior of your animal(s) we are not liable. We will do our best to keep everyone and everything safe – people, animals, and property.

Signature: I certify that the above information is complete and correct.

Barn & Home Veterinary Clinic

Mailing Address: PO Box 1314, Creswell, OR 97426 Phone: 541-735-4771 Email: clients@barnandhomevetclinic.com Website: www.barnandhomevetclinic.com