New Client Form Owner InformationName First Last Co-Owner’s Name First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone(Required)Work PhoneCo-Owner’s PhoneEmail(Required) Co-Owner's Email Preferred Form(s) of Contact(Required) Email Phone Alternate Contact (In case of emergency) Alternate Contact (In case of emergency)- PhoneHow did you hear about us?(Required) Referred by?Pet InformationPet's Name(Required) Species (dog, cat, etc.)(Required) Age/Date of Birth(Required) Sex(Required) Male Neutered Male Female Spayed Female Color(Required) Weight(lbs)(Required) Breed(Required) Know Allergies Do you have another pet?(Required) Yes No Would you like to make IVC your primary care veterinarian?(Required) Yes No Where was your pet previously seen?Hospital Name/City, State /Contact InfoHospital Name/City, State /Contact InfoHospital Name/City, State /Contact InfoIntegrative Medicine Questionnaire Circle 1-5/ Y-NOn a scale of 1-5, what is your understanding of integrative medicine? 1 2 3 4 5 How likely are you to choose natural/alternative supplements then medication, even if the results may be less immediate? 1(Least likely) 2 3 4 5(Most likely) Are you more likely to vaccinate or do vaccine titer testing for your pets? 1 (Give vaccine) 2 3 4 5(Titer test (to hopefully avoid vaccines)) Do you want to learn more about integrative medicine/alternative options for your pet? Yes No HOSPITAL POLICIES(Required) I agree to the privacy policy.We routinely prepare a written estimate. All professional fees are due at the time services are rendered. We accept MasterCard, Discover, Visa or American Express. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for treatment. I also understand I will be responsible for additional collection fees if an unpaid account is sent to the collection agency. I fully understand that this office does not staff outside of normal business hours.SIGNATURE OF CLIENT RESPONSIBLE FOR PET(S)(Required)Consent to Email for Appointment Reminders and Other Healthcare Communications:(Required) I agree to the privacy policy.You may be contacted via email to remind you of an appointment(s), to obtain feedback on your experience with our healthcare team, and to provide general health reminders/information. If at any time I provide an email, this gives IVC consent to use these as a means of communication for contact unless stated below., I consent to receiving appointment reminders and other healthcare communications/information at that email from the practice until I notify IVC of a change in my preferences. At times, our doctors and staff will use an app to make outgoing calls. These calls will sometimes come across as spam. If you put the clinic number in your contact list (804-325-1600), this will not occur.Do you consent to contact?(Required) Yes No The Integrative Veterinary Center of Richmond Payment Policy(Required) I agree to the privacy policy.Payment for office visits, procedures, and products is due in full, at the time services are rendered. Our staff is available to discuss our payment policy and your account at the time of the visit. As we do not offer bill options or payment plans. We accept Cash and all major Credit/Debit Cards. Past due accounts will receive an emailed statement each month and are due in full upon receipt. We reserve the right to impose a finance charge on all past due accounts. A billing fee of $5.00 will be added to the account balance upon the first statement being sent. For each additional monthly statement that is mailed out, a 1.5% finance charge will be imposed on all accounts. If my account becomes past due, and I have not contacted the office with a payment arrangement, the account may be forwarded to an attorney for collection. I will then become responsible for reasonable attorney’s fees and court costs involved in the collection of past due accounts. Should this occur, I agree to pay all attorney or collection agency fees (not to exceed 40%), and all court costs incurred by The Integrative Veterinary Center of Richmond.Appointments:(Required) I agree to the privacy policy.To meet the needs of all our clients, we see our patients by appointment only. We understand that from time to time, appointments may need to be changed or canceled. We request that appointments be canceled as soon as possible in order for us to better serve others with need. Appointments that are not kept, and are not canceled, significantly add to the cost of medical care. Therefore, appointments must be canceled more than 24 hours in advance or we must charge you for the visit. The charge will be based on the appointment type, and the time that was set aside for this appointment. Due to the high demand for appointments, we are requiring payment for any new patient visit at IVCRVA at the time of scheduling. We block anywhere from 45-90 minutes for new patient consults. No shows and last minute cancellations are becoming a problem and taking time from those who need to have their pets seen. Please note that this payment is non- refundable. If you call to cancel or reschedule 24 hours or more in advance, the money can be used to reschedule your appointment or be put towards other services or purchases at IVC for a period of one year. If you fail to contact us 24 hours or more before your appointment time, this money will be forfeited to IVC. This policy has become necessary to allow us to see new clients in a more timely manner and accommodate the increased demand for services as we grow. Thank you for understanding and we look forward to serving you and your pets.Statements:(Required) I agree to the privacy policy.I, the undersigned, agree to accept full financial responsibility for service rendered by The Integrative Veterinary Center of Richmond. I agree to abide by the conditions outlined in this payment policy.Social Media(Required) I agree to the privacy policy. I do not agree to the privacy policy I approve the use of any pictures taken of my pet by IVC for social media or other advertising.Signature(Required)Date(Required) MM slash DD slash YYYY CAPTCHA Δ
