New Client Form

Thank you for choosing MISCA for your veterinary specialty needs. We look forward to serving you and your pets.

All marked fields are required. Please clear your browsing history before completing this form.

Client Information

Title

Mr.Mrs.Ms.Mx.Dr.

Client Name(Required)

First Last

Address(Required)

Email(Required)

Primary E-mail Address:

Primary Contact Phone:(Required)

Cell

Work

Home

Cell Phone

Work Phone

Home Phone

Occupation(Required)

Alternate/Secondary Contact:

Alternate/Secondary Contact Phone:

Cell

Work

Home

Cell Phone

Work Phone

Home Phone

List all veterinary clinics where your pet has been treated:(Required)

Do you have Trupanion Pet Insurance?(Required)

Yes

No

Trupanion Pet Policy Number

Patient Information

Pet Name(Required)

Approximate Age/Birthdate:(Required)

Sex:(Required)

Male

Female

Spayed/Neutered:(Required)

Yes

No

Species(Required)

Canine

Feline

Indoor / Outdoor?(Required)

Indoor Only

Outdoor Only

Indoor / Outdoor

Breed:(Required)

Color:(Required)

Reason for referral:(Required)

Please provide a brief description of your pet's medical problem(s):(Required)

Please list all medications including dosage and dosing interval:(Required)

Please indicate your family’s preferred pharmacy including location and phone number (e.g. Walgreens, CVS, Costco, none)(Required)

Please list all foods and treats including frequency and amount per feeding(Required)

Image and Information Consent: MISCA periodically presents at educational conferences and distributes educational literature on the medical conditions we treat and the procedures we perform. I authorize MISCA to: (1) use my pet's clinical findings, photographs, and videos in print media, brochures, the MISCA website, or on other media outlets; (2) use these materials without inspection or approval of the finished products; (3) use these materials without compensation.(Required)

I authorize and accept

As pet owner, I accept financial responsibility for the services that are performed on my pet. I understand MISCA does not accept cash as a form of payment.(Required)

I understand and accept financial responsibility

"No Show" / Cancellation Policy: At the time of scheduling the initial appointment, a $50.00 deposit is required. The deposit will be applied to the final invoice. If I were to cancel with less than 24 hr notice or fail to show up for the appointment, the deposit will be forfeited. At the time of scheduling a procedure, a deposit of the high end of my estimate is required. If I were to cancel with less than 24 hr notice or fail to show up for the procedure, I will forfeit a $150.00 cancellation fee.(Required)

I understand and accept

I agree to indemnify and hold MISCA harmless from and against any and all liability arising from any procedure. I understand that anesthetic procedures involve inherent risks which the attending veterinarian will discuss with me in advance of the procedure. In the event that additional treatment is required and the attending veterinarian is unable to reach me, I authorize the staff to provide such treatment, and I agree to be financially responsible.(Required)

I agree and accept

Signature

Please Type Full Name Here:(Required)

Today's Date(Required)

MM slash DD slash YYYY

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Phone

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