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.





    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, individual we may thank:


    First Cat

    Name:

    Breed:

    DOB:

    Sex:

    Color:

    Microchip #:


    Second Cat

    Name:

    Breed:

    DOB:

    Sex:

    Color:

    Microchip #:


    Third Cat

    Name:

    Breed:

    DOB:

    Sex:

    Color:

    Microchip #:

    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 business 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/Last minute cancellation 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. For New Clients, we will require a $105.00 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.

    2. We will now require a $60.00 deposit to reschedule/schedule any client that has had a previous No Show/No Call/Last minute cancellation appointment

    3. If a scheduled appointment is a no-show or last-minute cancellation there will be a $65.00 fee for current clients I have read this form, and I am fully aware of the above hospital policies. *Signature: (Please type your name)

    *Signature & Date: (Please type your name)