Name: Main Ridge Veterinary Clinic
Price range: $

Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Who else is authorised to make decisions about your pet's healthcare?

First

Last

Phone

How did you find out about our hospital? If you were referred by someone, who should we thank? *

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Do you have a second pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Do you have a third pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Do you have a fourth pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Do you have a fifth pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed (copy) *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Payment is due in full at the time that services are performed. If being admitted into the hospital, we cannot begin the care of your Pet until you have confirmed your desire to do so by 1. Payment in full is required on the day of appointment for any consultation/ procedure performed at the clinic. 2. An account keeping fee of $15.00 per month will be imposed on overdue accounts. 3. Accounts referred to a collection agency or solicitor will have all legal costs and commissions added to the amount due. 4. Overdue accounts will be subject to interest at the rate prescribed by the Penalty Interest Rate Act (vic) plus 2% on the monies overdue from the due date until payment is made. 5. I grant/agree that the Main Ridge Veterinary Clinic may, its representatives and employee/s the right to take photographs of my pet and use and publish the same in print and/or electronically. Including, for example, such purposes as publicity, illustration, advertising and web content. 6. Payment in full is required within 7 days for any farm visits. *

I have read and accept the financial policy.

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Welcome to Main Ridge Veterinary Clinic

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