New Patient Center

Thank you for choosing Mt. Pleasant Veterinary Clinic for the care of your beloved four-legged family member!

New Clients: Please fill out the form below to expedite your appointment.
Any previous vaccination or medical history can be emailed to Staff@MtPleasantVet.com.

For Surgical Patients

Client Information

* Indicates required field

New or Existing Client? *

New Existing

Client Name *

Spouse Name *

Email *

Cell Phone Number *

Work Phone Number *

Spouse Email *

Spouse Cell Phone Number *

Spouse Work Phone Number *

Employer Name *

Drivers License Number & Issue State *

Spouse Employer Name *

Spouse Drivers License Number & Issue State *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Please email any previous vaccination history to clinic
Attn: "Records for {Pet name} {Client last name}"
to Staff@MtPleasantVet.com. If email is unavailable, records can be faxed to 757-482-6885.

If you do not have any history from your previous vet, please list your pet(s) names, up to the two most recent clinics that you have visited, and location (city, state) of the clinic(s) or hospital(s)

Pet(s) and/or Clinic Names: *

PLEASE INDICATE HOW YOU CHOSE US *

Recommended by one of our clients Yellow Pages Online/Google Search Other

So that we may thank them, who recommended us to you? *

CREDIT POLICY:
In order for us to keep our fees as low as possible Mt. Pleasant Veterinary Clinic does not extend credit. Payment is due when services are rendered. We accept Visa, MasterCard, Care Credit, cash, or check. A minimum charge of $40.00 will be applied to any check returned for any reason. If a balance occurs on one's account it will carry a minimum annual interest rate of 18% and a minimum $2.00 per month statement fee.

By typing the names of all clients listed in the form you acknowledge and accept the policy. *

First

Last

I hereby acknowledge that I have read and accept the credit policy. Name: *

First

Last

PHOTO RELEASE AUTHORIZATION:
I hereby authorize, Mt. Pleasant Veterinary Clinic to photograph, copyright, or publish any photographic or video image of my pet. I understand that the purpose of the use or release of the photographic or video images will be for training or marketing purposes. The use or release of the images will either be made public or within Mt. Pleasant Veterinary Clinic, or both.

I hereby acknowledge that I have read and accept the photo release policy. Name: *

First

Last

I hereby acknowledge that I have read and accept the photo release policy. Name: *

First

Last

CANCELLATION POLICY:
To ensure prompt service for all of our clients, any appointments not canceled more than 24 hours prior to the appointment time or missed without contact will be subject to a $25.00 cancellation fee.

I hereby acknowledge that I have read and accept the cancellation policy. Name: *

First

Last

I hereby acknowledge that I have read and accept the cancellation policy. Name: *

First

Last

Submit