New Client Form

Name: Veterinarian
Brand: Eastown Veterinary Clinic

We are dedicated to providing thorough, quality care to our patients to help you make the most of every moment with them. We can continue to offer such care only if we receive prompt payment for our services and products. As such, we make the cost of care as easy and manageable as possible by offering several Payment Options.

If the information does not apply please list N/A or no.

Thank you for entrusting us to be your family’s new primary care veterinarian! We look forward to meeting you.

Please complete the following form and a member of our team
will text you within 48 business hours to set up an appointment.

Please check this box if you have already scheduled a tentative appointment with a member of our team.

Yes

Owner's Information

Owner's Name

First

Last

Primary Phone

Is This A Mobile Phone?

Mobile Phone (optional)

Would You Like To Opt-In To Text Communications?

Work Phone (optional)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Secondary Owner or Authorized Agent (optional)

Secondary Phone (optional)

Preferred Communication Method

Call

Text

How did you hear about Eastown Veterinary Clinic? (optional)

Referred by a friend / family member

Referred by my primary veterinarian

Google Search

Event

Other

Please list their name here so we may thank them!

Please list the name and phone number of your veterinarian and what service you were referred for.

Please list the name of the event

Other: Please specify

Would you like to add a second pet?

Yes

Name

Species

Canine (Dog)

Feline (Cat)

Breed

Gender

Neutered Male

Male

Female

Spayed Female

Pet's Birthday / Age

Coat Color

What are you looking to accomplish with this visit?

I want to establish care for my pet.

My pet is sick.

I am getting a new puppy / kitten and want to bring them in for care.

I was referred for a dental consult.

I was referred for an Ultra Sound.

Other

Does your pet have a history of fear, anxiety and/or aggression at previous clinics?

Does your dog have a history of the following reactive triggers?

Please list the symptoms your pet is showing

Congratulations! When will they officially be in your care?

Please list the name and phone number of the veterinarian who referred you.

Other

Please list the name and phone number of any previous clinic, shelter, or rescue so that we may obtain medical records. *If you renamed your pet, please include any prior names records may be listed under.

By providing this information, you are authorizing Eastown Veterinary Clinic to request the above-listed patient's medical records from the listed facility.

If you have physical copies of any prior medical records, please take a clear photo and upload them here. We are no longer accepting physical copies at the time of the appointment.

Drop files here

One file only.
100 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Please review the policies below and feel free to ask any questions at the time of scheduling your first appointment.

Appointment Scheduling and Cancellation Policy

At Eastown Veterinary Clinic, we provide high-quality, individualized medical care in a timely manner. In order to provide this care to as many patients as possible, we have implemented new appointment scheduling and cancellation policies effective beginning November 15th, 2022.

Appointment Confirmations and Cancellations
As a courtesy, we will reach out via text, email, and phone to confirm your scheduled appointment. If you need to reschedule or cancel your appointment, please call 616-451-1810 or text 616-404-3052. If it is outside of our business hours or a team member is unavailable, you may leave a detailed message on our voicemail. You will receive a confirmation of cancellation once this message is received.

Surgical and Dental Procedure Deposits
A deposit of $250 is required to schedule a surgical or dental procedure. This amount will be applied to your final invoice. In the event that you need to reschedule your pet's procedure, please notify us two business days prior to your procedure date to avoid losing your deposit

Forfeited Appointments
Appointments are in high demand, and your early cancellation will allow another patient access to timely veterinary care.

An appointment is considered forfeited in the following circumstances: Late arrivals exceeding 10 minutes after the scheduled start time. Any appointment canceled after 8:00 am the same day.

If an appointment is forfeited, a fee in the amount of an exam will be charged via invoice. This fee will need to be paid before any future appointments are scheduled.

I acknowledge and understand the Appointment Scheduling and Cancellation Policies.

Yes

Pharmacy Policy

At Eastown Veterinary Clinic, we take the safety and well-being of our patients as our top priority. To provide that care with the prescriptions given to our patients, we implemented the Pharmacy Policy effective January 1st, 2023.

We no longer submit nor authorize prescription refill authorizations through third-party pharmacies. The following third-party online pharmacies include but are not limited to; Chewy.com, 1-800- PetMeds, Amazon, and Allivet.

Our only authorized online pharmacy is Vets First Choice.

If you choose to make online purchases for pet prescriptions elsewhere, you may submit a prescription refill request on our website and pick up a written prescription at our office.

In order for the doctors at Eastown Veterinary Clinic to be able to prescribe medications and food we must have a valid Veterinary Client Patient Relationship (VCPR). To fulfill this requirement a doctor must have fully examined the patient in-person within the last 12 months.

Behavior patients will need to be examined minimally once per year and have a telehealth medication check-in minimally once per year. We are unable to fill prescriptions for patients not meeting this requirement.

I acknowledge and understand the Pharmacy Policy

Yes

Social Media & Marketing Authorization

We LOVE Your Pet! We also love sharing success stories, puppy/kitten visits, and general pup-dates about patients we adore. We also believe that our brand is better represented by our very own patients than by stock photos. Please let us know if you authorize us to use photos, videos, or case-specific information about your pet(s).

Please specify your wishes regarding the release of your pet’s medical records in the event of an emergency referral, specialty referral, or adoption application request.*

I would like Eastown Veterinary Clinic to speak directly to me prior to the release of any medical records.

Financial Policies

Our financial protocols are in place to ensure we are able to keep our doors open and provide exceptional care to our patients and clients.

Deposits are required, along with a signed estimate, for hospitalized stays and/or procedures, with full payment due at the time of discharge.

We will always provide you with an estimate of services before they are completed. Full payment is due at the time of services rendered for appointments and outpatient visits. We accept Cash, Personal Checks, Visa, MasterCard, American Express, Discover, or Care Credit. If payment is made by check and is returned due to non-sufficient funds, there is a $50.00 returned payment processing fee.

I acknowledge and understand the financial policies.

Yes

Please enter your name below to acknowledge and confirm the accuracy of all information listed in this form.

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