Harbor Road Veterinary Hospital

626 Saint George Road
South Thomaston, ME 04858

(207)354-0266

www.harborroadvet.com

New Client/Patient Form

Client Information (required)
First Name (required)
Last Name (required)
E-Mail Address (required) :
Mailing Address (required)
Street Address (required)
City (required)
,		State / Province (required)
Zip / Postal Code (required)
Street Address, if different than mailing address
Street Address
City
,		State / Province
Zip / Postal Code
Daytime Phone (required)
Phone TypePhone Number (required)
Evening/Home Phone (required)
Phone TypePhone Number (required)
Employer

Work Phone
Phone TypePhone Number
Spouse/Partner/Co-Owner Information
First Name
Last Name
Selection :
Daytime Phone
Phone TypePhone Number
Evening/Home Phone
Phone TypePhone Number
Spouse/Partner/Co-Owner Employer

Work Phone
Phone TypePhone Number
Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed

Sex (required)

Male
Female


Neutered/Spayed

Neutered
Spayed


Are your pets vaccines current?

Yes
No


Do you have pets medical records?

Yes
No


Are your pet's medical records at another veterinary practice? If yes, please call that practice and have those records emailed to staff@harborroadvet.com.

Yes
No


Name of Former Veterinary Practice

Would you like us to call or text you for your appointment

Call
Text


Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

You may use my pet's image and name on:
Harbor Road's Facebook page
Harbor Road's website
in-clinic postings
you may not use my pet's image

HARBOR ROAD POLICIES
CREDIT POLICY Harbor Road Veterinary Hospital has a “no billing” policy, which enables us to keep our fees low. All services performed at Harbor Road Veterinary Hospital are to be paid for when rendered. We do not accept postdated checks, but we do accept cash, checks, MasterCard, Visa and Discover. There is a billing charge of $1.00 per month on all statements, and an annual finance charge of 18% on all outstanding balances. Recovery of this debt will be pursued through our collection agency, and all costs associated with collecting any outstanding balances will be added to the balance due Harbor Road Veterinary Hospital. You agree to reimburse us the fees of any collection agency, which may be based on a percentage at a maximum of 50% of the debt, and all costs and expenses, including reasonable attorney fees, we incur in such collection efforts. WAIVER OF LIABILITY If my animal(s) should injure themselves in an escape attempt, refuse food, soil themselves, become ill or die while in the hospital, I will hold Harbor Road Veterinary Hospital and its staff free of any responsibility and/or liability in the absence of gross negligence. POLICY FOR HOSPITALIZED & BOARDED ANIMALS For reasons of health and safety, all animals hospitalized or boarded at Harbor Road Veterinary Hospital are required to have current vaccinations and be free of fleas. If necessary Harbor Road Veterinary Hospital will vaccinate animals to bring them up to date and/or will apply a topical flea treatment if fleas are found. All costs for these services will be the responsibility of the pet’s owner.

Please type your name as acknowledgement that you have read and accepted Harbor Road's policies.


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