Today's Date *

Have you ever brought a pet to Longmeadow Veterinary Clinic before? *

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Client Information

Name *

First

Last

Email *

Primary Phone *

Secondary Phone

My secondary contact number is:

Home Number
Cell Number
Work Number
Someone else's number

Address *

Address Line 1

Address Line 2

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Zip Code

How would you prefer to be contacted?

Is there an additional person you would like listed on this account? *

Yes
No

Additional Person's Name *

First

Last

Additional Person's Phone Number

In case of an emergency, is there anyone else (besides above listed contacts) who should be listed on your account and who has ongoing permission to make medical decisions for your pets? *

Yes
No

Emergency Contact's Name *

First

Last

Emergency Contact's Phone *

How did you hear about us?

Please list who referred you so we may thank them!

Patient Information

Pet's Name *

Species

Dog
Cat

Date of Birth/Age of Your Pet *

Breed and Color (if your cat is not a known breed, do they have long, medium, or short hair) *

Sex *

Male
Neutered Male
Female
Spayed Female

Is your pet microchipped?

Yes
No
I'm not sure

Primary reason for your visit to Longmeadow Veterinary Clinic? *

Do you already have a scheduled appointment? *

Yes
No
I scheduled an appointment through your website

Previous Veterinarian/Veterinary Hospital(s) *

If none, please let us know that!

Would you like to add another pet? *

Yes
No

Pet's Name *

Species

Dog
Cat

Date of Birth/Age of Your Pet *

Breed and Color (if your cat is not a known breed, do they have long, medium or short hair *

Sex *

Male
Neutered Male
Female
Spayed Female

Is your pet microchipped?

Yes
No
I'm not sure

Primary reason for your visit to Longmeadow Veterinary Clinic? *

Do you already have a scheduled appointment? *

Yes
No
I scheduled an appointment through your website

Previous Veterinarian/Veterinary Hospital(s) *

If none, please let us know that!

Client Policies and Procedures: We want you to be aware of and understand the following policies and procedures for all clients.

We must receive your pet's medical history and records from your previous veterinarian no less than 7 days prior to your appointment; otherwise, you will need to reschedule your appointment. *

I have read and understand

We love social media! Do we have your permission to post pictures and/or videos of your pet(s), you and your pets(s), and/or your pet(s) and our team on Facebook, Instagram, Twitter, our website, and any other marketing and/or social media outlets we may choose to use? *

Yes
No

Our practice is currently trialing out a new AI program in order to improve our documentation of medical records so each visit is recorded in order to transfer the visit notes into our electronic records. *

I have read and understand

We require a deposit for each visit in the amount of the exam fee. We also require a 48 hours notice of desired modifications or cancellations for appointments in order to request a refund. After 48 hours, the deposit is non-refundable *

I have read and understand

Longmeadow Veterinary Clinic uses email, text, and our own hospital app for communications regarding our patients' reminders for health care needs. Do we have your permission to contact you via email, text and/or our app regarding these reminders? *

Yes
No

Financial Policy: We do not bill. All fees are due at the time that services are rendered. we accept many different payment options, including all major credit cards (VISA, MasterCard, Discover, American Express), cash, check, CareCredit, and Scratchpay. As a courtesy, we do offer extended payment plans through the following outside sources: CareCredit and Scratchpay. *

I have read and accept the financial policy.

Code of Conduct: All Longmeadow Veterinary Clinic team members, clients, and patients must be treated with respect at all times. Pets must be leashed or in a carrier while in the parking lot, lobby, hallways, and any other area of the clinic where they may encounter other people and pets. Any concerns regarding your pet’s care or our client service will be addressed respectfully with a member of the management team. Please understand that emergencies and urgent visits may unexpectedly affect our schedule. We ask for your understanding as we provide life-saving care to these pets, and remember that we will do the same for your pet if/when the need arises. Please allow 72-business-hour notice for filling medication and food orders. The following behaviors will not be tolerated: verbal abuse, malicious or harmful statements about others, profanity or disrespect, any form of harassment or bullying, discriminatory comments or actions, intimidation tactics, and/or making threats. Failure to comply with the requests of our staff, including leashing/restraining your pet, etc. We reserve the right to discontinue services immediately if you are in violation of this code of conduct. (copy) *

I have read and accept the code of conduct.

By signing below, I am confirming that I have read and acknowledge the above policies. *

Clear Signature

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