New Client Form

Kingstowne Cat Clinic, LLC

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

Maintain my personal information for purposes of maintaining a record of myself and my pets.
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-7pm
Tuesday: 8am-6pm
Wednesday: 8am-6pm
Thursday: 8am-7pm
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 and Thursday: 8:00 am to 7:00 pm
2. Tuesday, Wednesday, and Friday: 8:00 am to 6:00 pm
3. 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 or Saturday (depending on the alternating weekend) 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

*Signature: (Please type your name)