Welcome Form -

Name*

First Last

Address*

Street Address City ZIP Code

Primary Phone*

Email*

Emergency Contact*

Emergency Phone*

How did you hear about us?*

Website
Social Media

Previous Veterinary Clinic*

Phone*

May we transfer your pet's medical history to our clinic?*

Yes
No

Is there anyone else who is authorized to pick up and/or make decisions regarding your pet(s)?*

Yes
No

Name

Contact

Are you an active member of the military/police/fire department?*

Yes
No

We require that full payment be made at the time services are rendered. We do not have a billing department and will not accept personal checks. We accept cash, Visa, American Express, Discover and MasterCard. If you believe you will have trouble paying for your bill, we do accept Scratch Pay and will be able to assist you in the application.

Our office visit fee is $65 and will be applied to examinations unless otherwise specified.

Patient Information

Pet's Name*

Age*

Date of Birth*

Gender*

Species*

Other

Color*

Breed*

Does your pet have allergies?*

Yes
No

If yes, please list allergies

Has your pet ever had a reaction to vaccines or medications?*

Yes
No

Has your pet ever had a history of seizure activity?*

Yes
No
Unsure

Add a Pet?*

Yes
No

Second Pet

Pet's Name

Age

Date of Birth*

Gender

Species

Other

Color

Breed

Does your pet have allergies?

Yes
No

If yes, please list allergies

Has your pet ever had a reaction to vaccines or medications?

Yes
No

Has your pet ever had a history of seizure activity?

Yes
No
Unsure

Add a Pet?

Yes
No

Third Pet

Pet's Name

Age

Date of Birth*

Gender

Species

Other

Color

Breed

Does your pet have allergies?

Yes
No

If yes, please list allergies

Has your pet ever had a reaction to vaccines or medications?

Yes
No

Has your pet ever had a history of seizure activity?

Yes
No
Unsure

Emergencies or Medical Illness:

Animal Kindness will attempt to contact and notify the owner if the pet would become ill during it's stay via the primary and emergency contact numbers provided. If the owner, or emergency contact, is unable to be reached, the veterinary on staff will use his/her judgement of the animal's health to proceed. If the animal's health demands quick action, and the owner is still unable to be contacted, the veterinary will administer medical and/or surgical treatment (at owner's expense) as needed until the owner can be reached.*

I authorize Animal Kindness's licensed personnel (Veterinarians / Licensed Veterinary Technicians) to use extraordinary measures on my pet(s). I authorize Animal Kindness's licensed personnel (Veterinarians / Licensed Veterinary Technicians) to use extraordinary measures on my pet(s).
I decline Animal Kindness's licensed personnel (Veterinarians / Licensed Veterinary Technicians) to use extraordinary measures on my pet(s). I decline Animal Kindness's licensed personnel (Veterinarians / Licensed Veterinary Technicians) to use extraordinary measures on my pet(s).

Payment Terms

I understand that I am responsible for all fees and associated costs of any and all services performed to my pet(s). I understand that at any point during my pet's examination I may request an estimate for any charges that may incur. I also understand that all services are to be paid in full at time my pet(s) are discharged or at time service is rendered. The fees for examinations, medications, boarding, grooming, and associated fees accumulated during my pet's visit are non-refundable.

Belongings

Animal Kindness will not be responsible for any damaged or lost personal belongings accompanied with your pets. Therefore, we ask that you do not bring anything precious or valuable during boarding/grooming sessions. We cannot guarantee bedding will be returned or in the same condition it was brought in as.

Abandonment

In the event of an animal not being collected within 14 days of the departure date, we will be forced to assume the animal has been abandoned. At this time the clinic is authorized to remedy the abandonment as described by Nevada law. I further understand that the abandonment does not release me of my financial obligation for services rendered, fees associated with abandonment, collection action, and/or legal services.

Temperament

are taken while the pet is boarded/groomed/hospitalized. We reserve the right to refuse service to anyone. Owners are liable for any damage inflicted upon staff or property by their animal(s). It is emphasized whilst every care and attention is given, that the staff is not injured due to your animal's behavior while boarding/grooming/hospitalized. In cases of extreme aggression, the owner will be notified of special circumstances that are taken while the pet is boarded/groomed/hospitalized. We reserve the right to refuse service to anyone.

Cancellation Policy:

Agreement*

I understand that if I need to change my appointment time or cancel it, that I must give at least a 24 hour notice so that the appointment time can be made available to another client on the waiting list. A NO-SHOW CANCELLATION FEE OF $30 WILL BE APPLIED TO YOUR ACCOUNT FOR MISSED APPOINTMENTS OR THOSE NOT CANCELLED ACCORDING TO THE 24 HOUR POLICY. If two appointments are missed without giving notice, client's are then required to pre-pay prior to scheduling any future appointments.

Social Media:

Occasionally we like to post photos of some of our favorite pets. Do we have permission to post photos of your pet on our website and/or social media pages?*

Yes
No

Business Hours and Overnight Hospitalization

During the hours outside our normal "business hours," hospitalized patients and boarders will be unattended unless otherwise specified. Occasionally we will have trained staff in attendance that is able to perform l limited duties instructed by our staff of Veterinarians outside of normal business hours. During business hours, all licensed staff, included Veterinarians, are in the building at all times and may extend past business hours dictated based on patient's needs. Cases in which patients are in need of constant observation are advised to transfer to an emergency facility. It is up to the owner's discretion on how he/she chooses to comply with the recommendations of the Veterinarian caring for their pet in which we feel are always in your pet's best interest.

Grooming Specific Policies:

Coat Condition:

I understand that this establishment puts my pet's comfort above all else. In the event that my pet's coat is matted, I understand that the groomer may have to shave the matts out rather than perform a painful dematting procedure. I also understand that if my pet is severely matted, that there is an increased risk for clipper burn or cuts to occur. I understand that all attempts will be made to prevent this, however in many extreme matt conditions, it is unavoidable. I also understand that matted pets take additional time to groom so there will be an additional fee added on the regular grooming price.

I hereby authorize my consent to the above policies and assume responsibility for all charges that are incurred during my pet(s) visit. I also understand that these charges are due at the time of release and that a deposit may be required for patients admitted for hospitalization.*

Please sign before submitting this form.

Welcome Form

Patient Information

Second Pet

Third Pet

Emergencies or Medical Illness:

Payment Terms

Belongings

Abandonment

Temperament

Cancellation Policy:

Social Media:

Business Hours and Overnight Hospitalization

Grooming Specific Policies:

Coat Condition:

Contact Us

Hours

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