New Client Form

To those of you who are new to us, we’re so glad to meet you!

To help us better understand your pet and provide a low-stress experience, please complete our Fear Free Pre-visit Questionnaire and bring it to your appointment.

Please also take a moment to complete the form below with all of the appropriate information so we may get to know you and your pet better.

Choose an option to begin(Required)

New client with a new pet

Existing client with a new pet

Pet Owner/Primary Contact(Required)

First Last

Owner's Spouse/Partner

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Place of Employment(Required)

Primary Phone(Required)

Is this a mobile number?(Required)

Yes

Secondary Phone

Is this a mobile number?

Yes

Email(Required)

Conway Veterinary Hospital, PPLC will not share email information. This is simply a convenient way for us to share info.

Preferred Method of Contact(Required)

Primary Phone

Secondary Phone

Your Pet's Health History

Pet's Name(Required)

Species(Required)

Dog

Cat

Other

Sex(Required)

Male

Male Neutered

Female

Female Spayed

Date(Required)

MM slash DD slash YYYY

Breed(Required)

Color(Required)

Is your pet microchipped?(Required)

Yes

Do you use heartworm prevention?(Required)

Yes

Do you use flea and tick prevention?(Required)

Yes

Has your pet ever had a dental cleaning?(Required)

Yes

Does your pet go swimming in lakes and/or streams?(Required)

Yes

Does your pet go hiking with you?(Required)

Yes

What symptoms of problems have you noticed about your pet? (Check all that apply)(Required)

Behavioral Problems

Breathing Problems

Depression

Eyes Bulging or Bloodshot

Lack of Appetite

Loss of Balance

Shaking Head/Itching

Increased Thirst and/or Urination

Weakness

Bleeding Gums/Bad Breath

Coughing

Disorientation

Gagging

Lameness

Scooting/Scratching

Sneezing

Vomiting/Diarrhea

Other...

Symptom or problem not listed(Required)

What is the reason for your office visit?(Required)

What brand of food do you feed your pet?(Required)

Current medications(Required)

Previous health conditions(Required)

Any concerns regarding behaviors? (Check all that apply)

Excessive Barking

Jumping

Overly Rambunctious

House Breaking

Nipping

Problems Around Children

Other...

Behavioral concern not listed(Required)

Would you like more information about any of the following? (Check all that apply)

Microchip

Dental Care

Flea/Tick/Heartworm Prevention

Nutrition

Vaccination

Nutrition

Allergies

FIV Testing

Spaying/Neutering

Lyme Disease

Leptospirosis

Something else...

More info on something not listed(Required)

Terms & Policies

Terms & Conditions

I am the legal owner (or duly authorized agent for the owner) of the pet described, and I hereby authorize the veterinarians and professional staff of Conway Veterinary Hospital, PLLC to examine, prescribe for, and treat said pet. I assume responsibility for all charges incurred in the care of my pet. I also understand that ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.

Type your name to agree and consent to these Terms & Conditions(Required)

Social Media Consent

At Conway Veterinary Hospital, we appreciate all of our clients and would love to make your pet Facebook and Instagram famous! Please give us your permission to share an image and story of your pet on social media with your consent below. We promise your personal information will not be shared.

Social Media Consent Choice(Required)

I consent to Conway Veterinary Hospital, PLLC sharing my pet on future social media posts

Please do not share my pet on social media

24-Hour Cancellation/No Show Policy

We understand that your time is very valuable to you, and to respect your time and that of ALL our clients, we will require 24-hour notice to cancel your appointment. We do understand that we all have busy lives and things can come up at the last minute from time to time, however, last minute cancellations and no shows will be subject to a cancellation fee that equals the value of the respective exam charge...

Typing your name means you agree and consent to our cancellation/no show policy(Required)

Late Fee Policy

While we understand that unforeseen circumstances may cause you to be a few minutes late for your pet’s appointment, we hope you understand that delay may prevent us from providing appropriate care for your pet without creating delays for our other clients and patients.

If you are more than 5 minutes late (for your 20 minute appointment), we will likely need to reschedule your pet’s appointment. If we can arrange our schedule to absorb the delay and still provide your pet’s care, you will see a $20 late fee added to your invoice.

Typing your name means you agree and consent to our late fee policy(Required)

Financial Policy

We know you have the best interest in mind for your pet. We strive to provide affordable services and accept several methods of payment; however, payment is due at the time of treatment. Each patient is charged with an appropriate exam fee which covers both the veterinarian examination and consultation. Additional fees are charged for services and diagnostic tests as determined by your pet’s condition. An estimate of these fees will be discussed with you and in some cases, a printed estimate will be generated prior to initiation of treatment.

We have several choices for payment of services provided. Conway Veterinary Hospital offers a no-interest payment plan pending approval through Care Credit. We accept personal checks (we DO NOT accept postdated checks), Visa, Mastercard, Discover, American Express, and debit cards. Care Credit is a payment plan established through GECredit that allows you to start treatment today and spread payments over time. You can learn more about and apply for Care Credit by clicking here. Applying for Care Credit only takes a few minutes and there is no fee to apply. If your application is declined, another form of payment listed below is required.

Payment Options:

Cash
Check
Debit Card
Visa / Mastercard / Discover/American Express
Care Credit
All Pet

I agree to pay for my pet's services in full the day of my appointment with one of these payment options(Required)

Credit Card Processing Fees

In the event that you choose to make payments via credit card, a card processing fee of 2.5% will be applied. This fee covers the charges for processing card transactions and is not included in the standard service fees. The card processing fee will be calculated as a percentage of the total invoice amount and will be clearly indicated when a card is entered. There is no fee for using a debit card.

Credit Card Fee Acceptance(Required)

Initial here to acknowledge and agree to the application of this fee when opting to pay by card. The specific percentage for the card processing fee can be subject to change and if so, we will communicate as early as possible.

New Client Form

Your Pet's Health History

Terms & Policies

Expert Veterinary Care in Conway, NH