New Client Form

    Kingstowne Cat Clinic, LLC

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

    1. Maintain my personal information for the purpose of maintaining a record of myself and my pets.
    2. Transmit my pet or pet’s medical records to the facility of my choice, should I so request or request that facility to request. I understand that there may be a charge to do so.

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




    Owner Information

    Owner's Name: * required

    Spouse/Other: * required

    Owners Address: * required

    City: * required

    State: * required

    Zip Code: * required

    Home Phone:

    Cell Phone:

    Work Phone:

    Other Phone:

    Main Email Address:

    Occupation:

    How do you prefer to be contacted:

    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 $110.00 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 $65.00 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 and enter date below) * both required