New Client Information Form

New Client Information
Referring Doctor*
Please enter referring doctor's name. If you were not referred by your regular veterinarian then please enter Self-Referral.
Referring Hospital*
Please enter referring hospital's name. If you were not referred by your regular hospital then please enter Self-Referral.
Pet Owner's Name*
First Last
Significant Other
Address
Street Address Address Line 2 City State ZIP Code
Primary Phone Number*
Home Phone Number
Cell Phone Number
Work Phone Number
Pet Information
Pet's Name*
Species*
- Canine
- Feline
Breed*
Please enter your Pet's breed if you know it. If not, then please enter unknown.
Color*
Date of Birth/ Age*
Rabies Exp. Date
Sex*
- Male
- Neutered
- Female
- Spayed
Reason for Visit*
New Client Consent
Thank you so much for choosing Sierra Veterinary Specialists (SVS). We understand that you have many options when it comes to the care and treatment of your companion. We appreciate the opportunity to show you what we do best.*
Enter your initials above to agree.
In an effort to simplify the billing process, all payments are due when services are rendered. If you have elected surgery for your companion, all surgery fees are payable prior to your pet being discharged from the hospital. For your convenience, SVS accepts the following forms of payment: cash, check, Visa, Mastercard, American Express, Discover, Care Credit, and Wells Fargo Financial.*
Enter your initials above to agree.
Our practice also offers Care Credit or Wells Fargo Financial, a low interest, low monthly payment plan that you can use to take care of the balance of your account. If Care Credit or Wells Fargo Financial is of interest to you, please see our front office coordinator prior to scheduling surgery.*
Enter your initials above to agree.
I understand that my regular veterinarian has referred me to Sierra Veterinary Specialists (SVS) for specialty surgical and/or trauma management/treatment. I agree that I will not seek or try to obtain general veterinary services from SVS. I understand that SVS will not provide general veterinary services.*
Enter your initials above to agree.
Our facility does offer on-site overnight nursing care for our patients from 6:00 pm - 8:00 am Monday through Friday and all day Saturdays, Sundays and Holidays.*
Enter your initials above to agree.
Your signature below releases SVS of all liability in case of an accident of injury incurred while in transport and/or in the care of a SVS staff member.*
Enter your initials above to agree.
Case Study Consent
I authorize Sierra Veterinary Specialists to use any photos taken by their hospital to be posted on their SVS Facebook. Please enter Declined if you do not wish to take part in SVS Case Studies.
Patient Name
Owner Signature
Typing your name here acts as your digital signature.
Payment Policy
All fees are due at the time services are rendered. No credit will be extended. Deposits are required for medical care/critical care provided by Sierra Veterinary Specialists. If you have any questions or concerns regarding our policy, a staff member will be happy to address them prior to services rendered. We accept the following: CASH, PERSONAL CHECK, VISA, MASTERCARD, AMERICAN EXPRESS, DISCOVER AND CARE CREDIT. I authorize Sierra Veterinary Specialists to institute legal action if my account becomes delinquent or if I am negligent of the above financial arrangements. I am the legal owner, or representative of the legal owner, of the animal being presented for treatment. I hereby consent Sierra Veterinary Specialists to receive, prescribe for, treat or perform necessary surgery on my animal upon release.
Signature*
Typing name above acts as your digital signature.
Date*
Name
This field is for validation purposes and should be left unchanged.