Name *

First

Last

Email *

Primary Phone *

Secondary Phone

This text message program is provided to clients to notify clients of prescription refills and to follow up after appointments. Your information will not be sold, distributed, or in any other way shared with entities or affiliates outside of Brandon Lakes Animal Hospital.

Preferred Contact Method

Email
Phone

Please check your preferred method to be contacted regarding your pet, this includes status updates and test results from your pet's recent visit

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Who else is authorized to make decisions about your pet's healthcare? *

First

Last

Phone

How did you find out about our hospital? If you were referred by someone, who should we thank? *

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Current Medications

Current Medical Problems

I authorize Brandon Lakes Animal Hospital to take and/or post pictures of my pet.

Yes
No

Records Release: In accordance with the Florida State veterinary law regarding the confidentiality of patient medical records and treatment, a written authorization or other form of waiver executed by the client is required in order for us to provide a copy of your pet's medical records. By signing below you certify that you are the owner and/or agent and have the authorization to make medical and legal decisions for animals listed on your account. You hereby authorize Brandon Lakes Animal Hospital to release your animal's medical records to the requested person or veterinary facility. By signing this document, I herby release Brandon Lakes Animal Hospital and DVM's from any liabilities regarding release of records. *

I have read and above statement

All Fees Are Due Upon Patient's Release: We will provide a written estimate of fees before any treatment is administered. The actual cost of treatment may vary depending on factors not evident at the time of original examination. A deposit is REQUIRED if animal is hospitalized for treatment. We DO NOT ACCEPT checks as payment from new clients. We accept Cash, Credit Cards (MasterCard, Visa, and American Express) or Debit Cards. The cardholder MUST be present at the time of payment. *

I have read and above statement

Payment is expected at the time of service. If your pet is to stay with us in the hospital we will collect the full estimated treatment plan charges at the time we admit your animal, any additional services are due when you pick up your pet from the hospital. If a credit is on the account you may elect to have the monies returned to you or left on the account for future use. We do not make payment arrangements; we do however offer a variety of payment options. We accept the following forms of payment. We apologize but we are not able to accept checks as a form of payment from new clients. *

I have read and above statement

Signature *

Please sign to acknowledge that you have read & understand our policies above.

Date / Time *

New Client Form

Brandon Lakes Animal Hospital New Client

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