Exciting Update! Urgent Care Services are now available! Click HERE to learn more!

(715) 389-1011

Home
Our Hospital
Services
New Clients
- New Client Form
Online Store
Contact Us
Urgent Care

Home New Client Form

New Client Form

Today's Date

MM slash DD slash YYYY

Date of Appointment

(Put N/A if you do not have an appointment scheduled)

Owner Information

Have you been to Castlerock before?(Required)

Yes

Owner(Required)

Phone Number(Required)

Secondary

Phone Number

Address(Required)

Street Address

City

State / Province / Region

ZIP / Postal Code

Email Address(Required)

Preferred Contact Method(Required)

Call

Text

How did you learn about us?(Required)

Individual

Website/ Facebook

Primary Vet

Sign

Our staff uses a scribing application that aides in the note taking process during exams. Do you consent to the using this during your visit? (Please let us know if you would like a copy of the release)(Required)

Yes, I consent to them using

No, I would like to decline

Pet Information

Name(Required)

DOB/Estimated Age(Required)

MM slash DD slash YYYY

Sex

Breed

Color

Spayed/Neutered(Required)

Yes

Species(Required)

Cat

Dog

Other

Previous/ Primary Veterinary Clinic

Do you want us to send a copy of the exam performed today to your primary veterinarian?(Required)

Yes, I am continuing care at my primary veterinarian only

No, I want to continue primary veterinary care here, and I authorize Castlerock Veterinary Hospital to call and gather records for me

Replace the CPR consent to state(Required)

I wish for CPR to be performed, and I understand I would be contacted immediately by staff. I understand resuscitation may cost up to $600

Hospital Financial Policy

PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED. An estimate will be provided after the initial assessment of your pet. In the event of hospitalization, a deposit of 100% of the lower end of the estimate will be due at the time of admission. Payment, in full, is due at the time of discharge. We understand that visiting us on an urgent basis can be stressful, and that treatment costs may be more than anticipated due to the nature of your pet's medical problem. Often, friends and family may be able to help in a crisis. If you have any financial concerns or questions about our policies, please see one of our knowledgeable staff. Please see alternative sources of funding below(Required)

Cash

Credit/Debit

Care Credit (we may need proof of available funds before services are given)

Scratch Pay

By signing the line below, I am stating that I am the owner of this pet. If i am an “acting agent” (not the owner) I have made the staff aware, and arrangments have already been made between Castlerock and the pet’s owner stating I am authorized to approve treatments.

Permission to Treat:

I authorize the doctors to perform treatment for my pet. Payment in full is due at the time of service. I assume responsibility for all charges incurred in the care of this animal. If my pet requires admission to the hospital, I understand emergency veterinary care is not intended to be a subsitute for complete veteriary care.

Signature(Required)