New Client Paperwork How did you find out about us? Yelp Larchmont Chronicle Drove By Friend/Family Other Please specify Name* Address* City* State* Zip Code* Phone Number 1*Phone Type* Home Cell Work Phone Number 2*Phone Type* Home Cell Work Email* Occupation* Employer* Driver License* Date of Birth* MM slash DD slash YYYY Alternate ContactName Relation Phone Number*Phone Type* Home Cell Work Pet #1 InformationPet Name* Type of Pet* Dog Cat Other Please specify Breed Age Color Male / Female* Male Female Spayed / Neutered / Intact* Spayed Neutered Intact Previous Vet (Optional) - (Used to retrieve pets' medical history) Pet #2 InformationPet Name* Type of Pet* Dog Cat Other Please specify Breed Age Color Male / Female* Male Female Spayed / Neutered / Intact* Spayed Neutered Intact Previous Vet (Optional) - (Used to retrieve pets' medical history) I hereby authorize the veterinarian to examine, prescribe for and/or treat the above described pet(s). I assume all responsibility for all charges incurred in the care of these pet(s). I also understand that all professional fees are due at the time services are rendered.SignatureDate MM slash DD slash YYYY APPOINTMENT CANCELLATION POLICY At Hancock Park Veterinary Clinic, your scheduled appointment time is reserved just for you and your pet. We try not to overbook appointment times in order to provide excellent veterinary care and to be sure we have sufficient time to adequately examine your pet and to discuss your pet’s condition and treatment options in detail with you. We will make every effort to accommodate your scheduling needs. In return, we ask that you help us by keeping your scheduled appointments, arriving on time, and notifying us a minimum of twenty-four (24) hours in advance if you are unable to do so. When we receive advance notice of cancellations, our day runs more efficiently and more importantly we are able to see other patients who need care. Failure to comply with this policy will necessitate the following: Our staff will call to ensure the well being of you and your pet in addition to rescheduling your exam. An appointment deposit will then be required in order to reschedule at that time or for the next appointment scheduled. This deposit will be used towards the cost of the exam scheduled. If a 24 hour notice for cancellation is again not given, this deposit would be forfeited and taken as payment for the missed appointment. Repeated breaks of this policy will result in prepayments being required, indefinitely. - $65.00 deposit→ DVM appointment - $25.00 deposit → Technician appointment - Surgery appointment will require deposit of the low end of the surgery estimate. - Ultrasound appointment will require a deposit of $100. A 15 minute grace period will be given to Doctor's appointments and 10 minutes for technician appointments; if you arrive later than this you may be asked to reschedule unless stated otherwise by the DVM or technician. Wait times may be considerable. Please sign below that you have read and understand this policy:SignatureDate MM slash DD slash YYYY
