New Client Information Form | Charlottesville Cat Care Clinic

Charlottesville Cat Care Clinic
1901 Seminole Trail, Charlottesville, VA 22901
434-975-CATS (2287) Fax: 434-973-7640

Thank you for giving our hospital the opportunity to care for your cat.

Tell us about you!

Have any of your cats ever been a patient here?*

Yes
No

Name

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address (if different from above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Business Phone

Other Phone

Place of Employment

Department

Email

Can we send you e-mail or text reminders for your cat’s appointments, vaccine due dates, etc.?*

Yes
No

Who else shares responsibility for your cat?

Name

Relationship

Address (if different from above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Business Phone

Cell Phone

Place of Employment

Their Email

How did you hear about us?

How did you hear about us?*

List websites

Name of person or hospital that referred you to us

Payment Policy

FULL PAYMENT IS EXPECTED UPON RENDERING SERVICE. Deposits may be required on major medical/surgical cases, trauma cases and emergency work where hospitalization is required. We DO NOT carry open accounts and hope these alternatives are convenient to you:

Primary payment method*

I authorize the Charlottesville Cat Care Clinic and its staff to admit my cat and to administer vaccinations, medications, anesthetics, surgical procedures, tests, and necessary treatments that Dr. Mahanes and her associates find appropriate for the health, safety, and comfort of my cat while in their care. I understand that if my cat is found to have internal or external parasites (fleas, mites, worms, etc.), he/she will be treated at my expense. If any treatments not previously discussed with the owner are found to be necessary, all attempts will be made to contact the owner before they are administered. Missed or cancelled appointments, without 24 hours prior notification, are subject to a Missed Appointment Fee. In case of non-payment, a finance charge of 2 % monthly (24% annually) with a $5 minimum, and any collection and/or attorney fees will be paid by me.

A $35 charge will be assessed for all returned checks. If payment will be made by check, PLEASE provide your Driver’s License Number.

You may also be asked to provide identification if payment is made by check.

Drivers License Number

I have read and understand the above authorization*

Signature of owner or authorized representative

Date*

I understand that this form will be a permanent part of my cat’s record

Virginia Veterinary Disclosure

The commonwealth of Virginia requires the disclosure of veterinary hospital staffing hours upon the admission of a pet for medical therapy. The Charlottesville Cat Care Clinic is staffed from 8 am until 5:30 pm Monday, Wednesday, and Friday. And from 8 am until 7:30 pm Tuesday and Thursday. We are open Saturdays 9am until 1 pm. Dr Mahanes and her staff will provide intensive care or monitoring as necessary until a patient is stable regardless of day or time. If your cat is not stable, then transfer plans will be discussed by the on call Veterinarian and owner. Otherwise, there is no continuous care between the hours of: 5:30pm and 8am on Mondays, Wednesdays and Fridays; 7:30pm and 8am Tuesdays and Thursdays; and 1pm Saturdays thru 8am Mondays. All cats will be cared for (fed, watered, medicated, etc.) twice daily or more often as needed.

I have read and understand the above authorization:*

Signature of owner or authorized representative

Date*