New Client Form

Please complete this form as completely and accurately as possible so we can get to know you and your pet before your visit.

Pumpkin Hill Veterinary Clinic is granted permission to use and/or publish my or my pet's photograph or image (including audio, film, digital image, or other media) for educational purposes on their respective websites or for the promotion of their supported products. I understand that I and my pets are not being compensated in any way for the use of our images and that I/we do not have approval over the final product in which it appears. I hereby release Pumpkin Hill Veterinary Clinic and all persons acting under their permission or authority from any and all claims of liability arising out of the use of our images. This release shall bind our heirs, guardians, assigns, and legal representatives.

Subscriber uses PetDesk° R to manage client communications, vaccination reminders, appointment confirmations health alerts, product recalls, clinic alerts and product recommendations. You agree that we may share your name, pet's name, email address, address, and phone number with only PetDesk to facilitate this process. To learn more about PetDesk or their privacy policies please visit www.PetDesk.com or download their iOS or Android mobile applications.

Vaccine Dates: (Please provide paperwork for our records)

** In Signing below, I agree that the above information is true and accurate:

In bringing my pets to Pumpkin Hill Veterinary Clinic I understand the following:

- I understand that with my signed consent I effectively authorize at the time of visit(s) all treatments `performed by licensed staff.
- I assume financial responsibility for all charges incurred and agree to pay all such charges at the time medical care services are rendered or as arranged prior to the examination and/or treatment of my animal(s).
- I understand that a $300-$350 deposit is required at the time of admittance for hospitalized animals. - I understand that there may be an additional $25.00 fee for “walk-in service,” without a prior scheduled appointment.
- I understand that the use of retractable leashes is prohibited as a form of pet restraint at PHVC and could result in serious legal liabilities for a pet owner.
- I understand that any balance over 14 days will be sent to a collection agency and further services will be prohibited.
- I understand that there will be an additional charge of $35.00 for all returned checks.

** In signing below, I certify that I have read, understand and comply to agree with the above conditions. I also agree that the information I have provided above is accurate:**