New Client Form

    Kingstowne Cat Clinic, LLC

    I hereby give my permission to the business entity known as the Kingstowne Cat Clinic to:

    1. Maintain my personal information for purposes of maintaining a record of myself and my pets.
    2. Transmit my pet or pet’s medical record to the facility of my choice, should I so request it.

    Furthermore, I understand that payment is due at time of services rendered. I understand that the Kingstowne Cat Clinic is unable to serve as a creditor and cannot extend credit for services rendered.

    Please be advised: Kingstowne Cat Clinic does not have in-house care, 24 hour medical staff outside of normal business hours which are as follows:
    Monday: 8am-6pm
    Tuesday: 8am-6pm
    Wednesday: 8am-6pm
    Thursday: 8am-6pm
    Friday: 8am-6pm

    In the event of an overnight surgery or boarding, a staff member will be here to check on/provide food and any medications twice daily.

    Owner Information

    Owner's Name:

    Spouse/Other:

    Address:

    City:

    State:

    Zip:

    Email:

    Occupation:

    Home Phone:

    Cell Phone:

    How do you prefer we contact you?:

    How did you hear about our practice?:

    If referred, please provide the name:

    First Kitty

    Name:

    Breed:

    DOB:

    Sex:

    Color:

    Microchip #:

    Second Kitty

    Name:

    Breed:

    DOB:

    Sex:

    Color:

    Microchip #:

    Third Kitty

    Name:

    Breed:

    DOB:

    Sex:

    Color:

    Microchip #:

    Upload Records:

    Please Read Carefully Before Signing

    Kingstowne Cat Clinic has business and medical staffing hours as follows:
    1. Monday- Friday: 8:00 am to 6:00 pm
    2. Weekends and Holidays: Closed
    Therefore, this is to inform you that we have no in-house, on duty continuous medical staff care on:
    a) Weekdays from Closing time until the following business day at 8:00 am.
    b) Weekends from Closing time on Fridays until 8:00 am on the following Monday.
    c) Holidays from Closing time before the Holiday until the opening time the day after the Holiday.

    Kingstowne Cat Clinic strives to provide the best possible care. Recently we have had an increase of No Show/No Call appointments. When this happens, it means another possibly sick patient couldn’t be seen at that time. To minimize this from happening we are implementing the following policies:
    1. We will now require a $55.00 deposit to reschedule/schedule any client that has had a previous No Show/No Call appointment.
    2. If you make it to your scheduled appointment, the $55.00 will be credited toward your exam.
    3. If you again do not make it to your scheduled appointment, there will be a No-Show Fee of $55.00.
    4. For New Clients, we will require a $95.00 deposit to go toward your first visit. If you do not make your scheduled appointment, the deposit will be charged as your Missed Appointment Fee.

    I have read this form and I am fully aware of the above hospital policies.

    *Signature: (Please type your name)