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 [email protected]

Client Information

* Indicates required field

New or Existing Client? *

New Existing

Client Name *

Alternate Owner/Spouse Name *

Email *

Cell Phone Number *

Alternate Phone Number *

Alternate Owner/Spouse Email *

Spouse Cell Phone Number *

Alternate Phone Number *

Employer Name *

Drivers License Number & Issue State *

Alternate Owner/Spouse Employer Name *

Alternate/Spouse Drivers License Number & Issue State *

Mailing Address *

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Line 2

City

State

Zip Code

Country

Residence Address (if different than mailing) *

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Line 2

City

State

Zip Code

Country

Please email any previous vaccination history to clinic at [email protected] or arrive 10-15 minutes early, and bring to your appointment. If email is unavailable, records can be faxed to 757-282-2618. Please list your pet(s) names, breed, age (or birthday, if known), and a brief description so that we can properly input the information into your record. If you do not have any history from your previous vet please list up to the two most recent clinics that you have visited and location (city and state) of the clinic or hospital.

Pet Name #1 *

Pet Name #2 *

Pet Name #3 *

Pet Breed #1 *

Pet Breed #2 *

Pet Breed #3 *

Pet Age/Birthday #1 *

Pet Age/Birthday #2 *

Pet Age/Birthday #3 *

Brief Description of Pet #1 *

Brief Description of Pet #2 *

Brief Description of Pet #3 *

Previous Vet(s) *

Additional pets/information *

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? *

If "Other": how did you hear about us? *

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, Discover, American Express, 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.

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

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Last

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

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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: *

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Last

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

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Last

CANCELLATION POLICY:
To ensure prompt service for all of our clients, any appointments not canceled more than 4 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: *

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Last

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

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Last

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