Owner’s Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Cell Phone *

Accepts Texts? *

Yes
No

Owner Email *

(*communication means for alerts, recalls, confirmations & medical health reminders)

Spouse / Sig. Other:

Spouse / Sig. Other Email:

Spouse / Sig. Other Home Phone

Spouse / Sig. Other Phone

Accepts Texts?

Yes
No

Financial Agreement

Payment Method *

In bringing my pets to Pumpkin Hill Veterinary Clinic I understand the following: (Please initial on the lines provided) *

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 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 and 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:

Signature of Owner or Responsible Party *

Clear Signature

Date *

Printed Name of Owner or Responsible Party *

Media Release

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.

Media Agreement *

I agree
I decline

Signature of Owner or Responsible Party: *

Clear Signature

If you decline, please Sign Here: *

Clear Signature

Date: *

Printed Name of Owner or Responsible Party: *

PetDesk® Release Statement

Subscriber uses PetDesk® 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.

Petdesk Agreement *

I agree
I decline

Signature of Owner or Responsible Party: *

Clear Signature

If you decline, please Sign Here: *

Clear Signature

Date: *

Printed Name of Owner or Responsible Party: *

Pumpkin Hill Veterinary Clinic

Pumpkin Hill Veterinary Clinic

Returning Client With New Patient Form

Returning Client With New Patient Form

Financial Agreement

Media Release

PetDesk® Release Statement

Pet Vaccines

Pet Annual Visits

Pet X-rays

Pet Ultrasounds

Pet Fecals and Urinalysis

Puppy/Kitten Visits

Pet Spays And Neuters

Vaccines

Annual Visits

X-rays

Ultrasounds

Fecals And Urinalysis

Herd Exams

Wound Repair

Annual Vaccines

Coggins Testing

Johne’s Testing

Health Certificates

Fair Checks

Fecal Testing

Pregnancy Checks

Hormone Regulation

Pet Acupuncture

Pet Chiropractic

Pet Chinese Herbs

Pet Cold Laser Therapy

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Have Questions?

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Contact Information

Hours