New Client Form Thank you for giving us the opportunity to care for your pet. Please help us to better meet your needs by taking a moment to complete this information.Owner's Name(Required) First Last Cell Phone(Required) Home Phone Email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Who else is authorized to make decisions about your pet’s healthcare (Name and Phone Number)(Required) Is this person to be listed as a second owner?(Required) Yes No Emergency Contact Name(Required) Emergency Contact Phone(Required) Is this person to be listed as a second owner?(Required) Yes No Who Can We Thank For Referring You To Our Hospital? We will gladly prepare an estimate upon request, please ask a customer service representative, nurse, or doctor. A deposit may be required for surgery and hospitalization. I hereby authorize the veterinarian to examine, prescribe for, and/or treat my pets. I assume full responsibility for all charges incurred for the care of all my pets on my file. I also understand that these charges will be paid at the time of services rendered. Collection service/attorney fees will be levied on all unpaid balances.(Required) I Understand Reminder Method: Rox Falls Vet uses email and text message for vaccine/exam reminders and appointment confirmations.(Required) I Understand To prevent the spread of infectious diseases and parasites, hospitalized and boarded animals must be current on all vaccines and free of internal and external parasites. I authorize the doctor to administer vaccines and parasite control as needed for my pet.(Required) I Understand I accept that there are potential risks with any vaccination, medication, or treatment provided. I accept that there is also potential risk with declining medical recommendations. I understand and release Rox Falls Vet of any liability associated. I understand it is my responsibility to contact Rox Falls Vet or seek care at an Emergency Hospital if any adverse reaction has occurred.(Required) I Understand Veterinary Hours DisclosureRox Falls Vet is continuously staffed by medical and business personnel during the following hours: Monday –Thursday: 9 AM to 7 PM (Doctor’s Hours 9AM to 6:30PM) Friday-Saturday-Sunday: 9 AM to 5 PM (Doctor’s Hours 9AM to 4:30PM) This schedule may be subject to change. Clients are referred to the website www.roxfallsvet.com and the hospital Facebook page for the most up to date hours or for emergency closures. Staffing is not provided at other hours or on the following holidays: New Year’s Day, Easter, Memorial Day, Fourth of July, Labor Day, Thanksgiving, or Christmas. Patients requiring continuous monitoring and medical treatment (i.e. intensive care) at times this hospital is closed can be transferred by the owners or their agent to a 24 hour facility where after hours staffing is provided. Any expenses incurred at another facility will be the responsibility of the owner. I have read and am aware of the staffing hours.(Required) I Agree Date(Required) MM slash DD slash YYYY Signature (Owner/Agent)(Required)PET INFORMATION #1Pet Name(Required) Species(Required) Feline Canine Other If Other Breed(Required) Color(Required) Age/DOB(Required) Sex(Required) Spayed or Neutered(Required) Yes No Unknown Is your pet currently up to date on vaccines?(Required) Yes No Microchipped?(Required) Yes No Unknown Number Name of previous veterinarian: Previous veterinarian’s phone number and/or city, state: Do we have permission to contact the previous veterinarian for records?(Required) Yes No Does this pet have pet insurance?(Required) Yes No If the insurance company reaches out to us, do we have permission to send them your pet’s file and notes? Yes No PET INFORMATION #2Pet Name Species Feline Canine Other If Other Breed Color Age/DOB Sex Spayed or Neutered Yes No Unknown Is your pet currently up to date on vaccines? Yes No Microchipped? Yes No Unknown Number Please provide the name of your previous veterinarian Do we have permission to contact the previous veterinarian for records? Yes No Does this pet have pet insurance?(Required) Yes No If the insurance company reaches out to us, do we have permission to send them your pet’s file and notes? Yes No Pet Photo ReleaseI grant Rox Falls Vet, its representatives, and employees the right to take photographs of my pet(s). I authorize Rox Falls Vet, its assignees and transferees to copyright, use, and publish the same in print as well as electronically. I agree that Rox Falls Vet may use these photographs of my pet(s) with my pet’s name for any lawful purpose, including use on Facebook, Instagram, on the Rox Falls Vet website, and in our clinic.(Required) I Agree I Decline DEPOSIT POLICYConsent(Required) For first-time clients, we do require a deposit to be paid at the time of booking a wellness weekend appointment on Fridays, Saturdays, and Sundays. The deposit is the cost of the appointment, and will go toward your final bill/appointment cost. For all clients wishing to book multiple pets on the same day, we also ask for deposits for each pet’s appointment, regardless of which day of the week it is. The deposit will be the cost of the appointment. For any clients (new or old) we require a deposit to be put down if they are trying to book a SAME DAY appointment on the WEEKENDS. (This does include Fridays). Clients will be required to pay a deposit upon booking equal to the cost of the consultation fee and it will go towards their final bill. If you cancel at least 1 hour before the scheduled start time, we will refund the deposit. If a cancellation, reschedule due to tardiness, or no show occurs within 1 hour of appointment, the deposit is forfeited by clients. I understand(Required)RFV APPOINTMENT CANCELLATION/NO-SHOW POLICYConsent(Required) If a cancellation is made prior to 1 hour before the appointment, the deposit can be refunded. If a cancellation, reschedule due to tardiness, or no-show occurs within 1 hour of the appointment, that deposit is forfeited by the client. If any client cancels within 1 hour or no-shows any appointment, either weekend or weekday, regardless of the type of the appointment, they will be required to pay the deposit equal to the office consultation fee for ALL visits moving forward. If such a cancellation or no-show occurs for a surgery appointment within 24 hours of the appointment, they will also be required to pay a deposit for future surgery appointments. This deposit will be equal to 25% of the high end of the surgical estimate. This deposit will be forfeited if the pet parent cancels again within 24 hours of the surgery. Our veterinarians and staff want to be available to your needs and the needs of all our clients and patients. When a client does not show up for a scheduled appointment, another patient loses an opportunity to be seen. Thank you for your understanding! I understand(Required)POLICY OF MUTUAL RESPECTWelcome to Rox Falls Vet! The Rox Falls Vet team greatly appreciates the trust that you place in us to care for your pet. Our commitment to partnering with you: To provide the highest standard of care for your pets, we maintain a professional environment built on mutual respect. Our team pledges to treat you with kindness, transparency, and clinical excellence. In turn, we ask that our clients meet the following expectations: Safety and Cooperation Restraint: All pets must be leashed or in a secure carrier while in common areas. Honesty: Please provide accurate medical and financial information so we can best assist you. Instructions: For the safety of your pet and our team, please follow all pet handling requests made by our doctors and staff. Our Policy of Mutual Respect We understand that having a sick pet is stressful. However, please remember our staff is here to help. To protect our team and other families, the following may result in immediate termination of services: Threats, intimidation, verbal abuse, or physical aggression. Harassment or discriminatory remarks of any kind. Cyberbullying & Digital Harassment Entering the premises under the influence of alcohol or drugs. Failure to pay for services rendered. *If you feel we have failed to meet our commitment of respect and professionalism toward you, please contact our Practice Manager or Owners directly. We value constructive feedback and are always trying to improve. Rox Falls Vet reserves the right to discontinue services if behaviors become problematic. This policy is enforced to ensure a safe and supportive environment for everyone involved. Thank you for allowing our team to help you, and keep your pets happy and healthy! Sincerely, Samantha Eberz, CVT, Practice Manager Stephanie Cohen, VMD, Practice Co-Owner Michael Altmeier, VMD, Practice Co-Owner(Required)Welcome to Rox Falls Vet! The Rox Falls Vet team greatly appreciates the trust that you place in us to care for your pet. Our commitment to partnering with you: To provide the highest standard of care for your pets, we maintain a professional environment built on mutual respect. Our team pledges to treat you with kindness, transparency, and clinical excellence. In turn, we ask that our clients meet the following expectations: Safety and Cooperation Restraint: All pets must be leashed or in a secure carrier while in common areas. Honesty: Please provide accurate medical and financial information so we can best assist you. Instructions: For the safety of your pet and our team, please follow all pet handling requests made by our doctors and staff. Our Policy of Mutual Respect We understand that having a sick pet is stressful. However, please remember our staff is here to help. To protect our team and other families, the following may result in immediate termination of services: Threats, intimidation, verbal abuse, or physical aggression. Harassment or discriminatory remarks of any kind. Cyberbullying & Digital Harassment Entering the premises under the influence of alcohol or drugs. Failure to pay for services rendered. *If you feel we have failed to meet our commitment of respect and professionalism toward you, please contact our Practice Manager or Owners directly. We value constructive feedback and are always trying to improve. Rox Falls Vet reserves the right to discontinue services if behaviors become problematic. This policy is enforced to ensure a safe and supportive environment for everyone involved. Thank you for allowing our team to help you, and keep your pets happy and healthy! Sincerely, Samantha Eberz, CVT, Practice Manager Stephanie Cohen, VMD, Practice Co-Owner Michael Altmeier, VMD, Practice Co-Owner I agree(Required)TRANSCRIPTION SERVICESIn an effort to streamline both efficiency and accuracy of medical records, RFV has enlisted a transcription service. It works by recording the audio of the office visit. This is completely optional for the client to allow this service. Please let the nurse or doctor know prior to the appointment if you have any objection to our medical team using this. If you understand and have no objection, please sign below. Thank you!(Required) I consent to transcription services I decline transcription services CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
Rox Falls Vet is continuously staffed by medical and business personnel during the following hours:
Monday –Thursday: 9 AM to 7 PM (Doctor’s Hours 9AM to 6:30PM)
Friday-Saturday-Sunday: 9 AM to 5 PM (Doctor’s Hours 9AM to 4:30PM)
