New Client Form

New Client Form

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form completely. If you have questions we will be glad to assist you.
Responsible Party *

First Name Last Name
Preferred Pronouns
Date of Birth *

Month Day Year
Date
Phone Number - Home

Area Code Phone Number
Phone Number - Cell

Area Code Phone Number
Phone Number - Work

Area Code Phone Number
E-mail
You will receive pet health reminders, appointment reminders and other information from us through email. You can opt out of any type of email communication through our online portal or the email itself.
Street Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mailing Address - If different from street address

Mailing Address

Street Address Line 2

City State / Province

Postal / Zip Code
Driver's License Number
Please include the state
Other Responsible Party's Name - This person has full authorization to make medical, financial, and account changes for all pets.

First Name Last Name
Phone Number

Area Code Phone Number
Alternate Emergency Contact - By listing an emergency contact you authorize said contact to make treatment and/or financial decisions for your pet in emergency situations when you cannot be reached.

First Name Last Name
Phone Number

Area Code Phone Number
How did you learn about our practice?
Please list the veterinarian, phone book, internet site, individual, or other
Preferred Communication Method
How we use your information

Mountain View Veterinary Health Center will never sell your information. All your personal information is kept in strict confidence as required by law. Your information may be shared with our business partners to provided better service to you (email and appointment reminders, online pet medical records, prescription home delivery services, HomeAgain pet rescue microchip database, etc.), but they will never sell or share your information. At times, aggregate data may be shared to better the field of veterinary medicine, but at no time will personal identifying information be given for statistical studies.
Financial Policy

Thank you for choosing Mountain View Veterinary Health Center. Our primary mission is to deliver the best and most comprehensive veterinary care available for your pet. An important part of the mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options.
Mountain View Veterinary Health Center requires payment in full at the end of your pet’s examination and/or at the time of the discharge.

Payment Options

- Cash, Visa®, MasterCard®, American Express® or Discover Card®,

- Check
o By paying by check, you authorize us or our agent to process the check by traditional deposit, electronically, or through a ‘preauthorized draft.’ If the check is returned for any reason, you authorize us or our agent to re-present the check one or more times by such methods, and you authorize us or our agent to collect a returned check fee up to the maximum amount as permitted by law.

- Convenient Monthly Payment Plans from CareCredit® - Subject to credit approval
o Allow you to begin treatment today and pay over time.
o Available for any treatment amount.
o Can be used repeatedly - for your entire family - without having to reapply.

- Payment Plans from ScratchPay - Subject to credit approval
o Risk Free: Scratchpay isn’t a credit card. Finding your payment plan will NOT affect your credit score.
o Highest Approvals: We approve more pet parents, with affordable rates as low as 0% APR.
o Friendly: No hidden fees. No prepayment penalty. No deferred interest. No surprises.
Deposit and Billing:

For some treatments or hospitalized care, a deposit is required. Treatment plans requiring comprehensive care of $300 or more require a 50% deposit to begin your pet’s treatment. Any other payment arrangements must be discussed and approved with the practice manager before any services are rendered. Mountain View Veterinary Health Center charges the maximum amount allowable by law for checks returned unpaid. We charge 1.75% per month (21% per year) interest with a minimum charge of $5.00 on all outstanding account balances older than 30 days including returned check balances. If you have an account 30 days past due, Mountain View Veterinary Health Center may relinquish your balance owed to an outside collection agency. Any balances referred to an outside collection agency will incur a collection referral fee of 40% and you will be responsible for all court costs and attorney’s fees associated with collecting your balance.

Additional Policy Information:

Mountain View Veterinary Health Center has posted business hours but does offer after-hours pick ups and drop off in certain cases. Any pets picked up or dropped off outside of our regular posted business hours for any reason will incur an after hours drop off/pick up fee. A fee of $45 may be charged for clients who miss or cancel more than 3 appointments or reservations in a calendar year without 24 hours notice. For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier.

Product Returns:

All product sales are final. This includes but is not limited to pet foods, controlled substances, prescription drugs, and over the counter products. In some cases where a manufacturer guarantees the product a return may be possible. We reserve the right charge a 10% restocking fee on all returned products and all returns must be approved by the practice manager and the attending veterinarian.
Please initial signifying you have read the financial policy *
Medical Records Confidentiality
Your personal information and pet’s medical record is completely confidential and protected by law. According to Utah’s Veterinary Practice Act (§ 58-28-605) on veterinarian-client-patient confidentiality, Mountain View Veterinary Health Center may not disclose information on our care of an animal to anyone other than the client, as defined in Section 58-28-102, unless:

- the client consents to the disclosure in writing;

- disclosure to public health officials, animal health or welfare officials, agricultural authorities, or federal, state, or local officials is required, or necessary to protect the animal or to protect public health;

- disclosure is required by court order or subpoena; or

- the client has placed the veterinarian's care or treatment of the animal or the nature or extent of injuries to the animal at issue in a civil or criminal proceeding.

Mountain View Veterinary Health Center takes the confidentiality of your personal information and your pet’s medical record very seriously. We do not and cannot release this information without your express written consent. At times we may share your information with our third-party partners to enhance your veterinary experience. These partners are contracted by us and use/follow the guidelines we set forth in regard to confidentiality of your information. These partners are hired by Mountain View Veterinary Health Center to provide specific client services and will never use your information for their own purposes. In the case of microchipping your pet certain personal information and your pet’s name will be released to HomeAgain to register your pet with HomeAgain pet recovery service. At times we may release test results or diagnoses to research organizations to better the veterinary field and treatment regimes, but in no way will identifying or personal information be released.

At times you may wish us to release certain medical information to boarding, grooming, and/or other veterinary hospitals. We are happy to provide this information, but must have written consent from you to release this information. We wish to provide the best customer service possible to you so we ask you to please choose one of the options below on how to provide this service to you:
Please choose one *

I authorize Mountain View Veterinary Health Center and give written consent to release vaccine records and other pertinent medical information on my pet(s) at the discretion of the staff of Mountain View Veterinary Health Center. Please do not release any of my pet(s)’ medical information without written consent. I understand I must provide consent in writing each and every time a request for medical records is initiated including releasing records to myself.
This agreement will remain in full force until a request in writing is made by the owner/agent of the pet(s) revoking this authorization.
Extra-Label Drug Use
The Food and Drug Administration (FDA) oversees the licensing of pharmaceuticals for humans and animals. Many drugs that have been approved for use in humans and/or some animals have also been proven to be safe and effective in species for which the drugs are not labeled. Drugs are considered to be used in an “extra-label” manner when a FDA-approved drug is used to treat a different species than it was approved for.

Extra-label use does not include the use of experimental drugs or drugs manufactured in foreign countries that have not been approved by the FDA. Despite this lack of FDA approval, it may be necessary to occasionally use such drugs when no other effective options exist.

All drugs can potentially cause harmful side effects, including death. The drugs that will be used for your pet at Mountain View Veterinary Health Center have been safely used in individuals of the same or related species. When a drug must be used to treat an unusual disease or an unusual species, effectiveness and safety can be difficult to predict. You will be advised when your pet has been prescribed a medication that has not been given to a significant number of individuals of a similar species with a similar medical condition.
I have read and understand the above policy on the use of extra-label pharmaceuticals. I authorize the staff at Mountain View Veterinary Health Center to administer and prescribe extra-label drugs for my pet. I understand that any drug, including those that are used in an extra-label manner, can produce undesirable side effects. Thus, I acknowledge that it is my responsibility to administer prescribed medications for my pet as directed and to notify my veterinarian of any apparent side effects or complications. Please initial: *
Permission to Use Photograph
Please choose one: *

I grant Mountain View Veterinary Health Center, its representatives and employees the right to take photographs of me, my pet(s), and my property in connection with visits and veterinary care by Mountain View Veterinary Health Center. I authorize Mountain View Veterinary Health Center, its assigns and transferees to copyright, use, and publish the same in print and/or electronically.I agree that Mountain View Veterinary Health Center may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. Please do not copyright, use, and publish photographs of me, my pet(s), and my property.
*
By signing below, you agree to all terms and policies listed in this form. You certify you are eighteen years of age or over, and you have full and exclusive authority to make financial and medical decisions for all pets listed on your account. *
Should be Empty:

New Client Form

How we use your information

Financial Policy

Medical Records Confidentiality

Extra-Label Drug Use

Permission to Use Photograph