"*" indicates required fields Client informationDate of Birth* MM slash DD slash YYYY The DEA and State of California require the owner's birth date for use of all controlled substances. Many medications used for sedation and pain management are controlled substances. Date MM slash DD slash YYYY Owner Name* First Last Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Primary phone number*by providing your Phone number you are opt-in for SMS communication. Secondary phoneby providing your Phone number you are opt-in for SMS communication. Drivers license*Social security number*Do you currently have an appointment with BVH?* Yes No If yes, what date is that appointment? MM slash DD slash YYYY Pet Information and HistoryName of Pet*Species*DogCatHorseOtherBreed*Color*Birthdate*Sex*MaleNeuteredFemaleSpayedVaccination History (please put last date given):DHLP&PBORDETELLARABIESFELEUKFELEURVIs your pet currently on any medications? (Please list all)2nd Pet Information and HistoryName of PetSpeciesDogCatHorseOtherBreedColorBirthdateSexMaleNeuteredFemaleSpayedVaccination History (please put last date given):DHLP&PBORDETELLARABIESFELEUKFELEURVIs your pet currently on any medications? (Please list all)AUTHORIZATION: I hereby authorize the veterinarian to examine, prescribe for, and/or treat the above described pet and/or pets. I assume full responsibility for all charges incurred for the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment or hospitalization. We accept the following payment types: Cash, Check, Mastercard, Visa, American Express, Discover and Care Credit.*Date* MM slash DD slash YYYY Financial PolicyThank you for choosing Bishop Veterinary Hospital. 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. Appointments: Walk-in emergency appointments are welcome, however, scheduled appointments are preferred. Emergency cases are given top priority followed by patients with scheduled appointments. There is an additional charge for walk-in non-emergency appointments. Deposit and Billing: All new clients of Bishop Veterinary Hospital will be required to pay the cost of the exam deposit, by credit card at the time of booking. The cost of the exam will be applied to your first visit. In the event of needing to cancel your first appointment with Bishop Veterinary Hospital, we may refund your deposit or reschedule your appointment if given a 24hour notice. The deposit will be forfeited should notice of cancellation be less than 24-hours or a failure to attend an appointment. This policy was established in September 2023 due to multiple new client late cancellations and no-show appointments. Payment Options: We require full payment at the time of service. You can choose from: Cash, Check, Visa, MasterCard, Discover Card, American Express, or Debit. Convenient Monthly Payment Plans from Care Credit Additional Policy Information: Bishop Veterinary Hospital charges $15 for returned checks. A fee of $25 may be charged for clients who miss or cancel more than 3 consecutive appointments without at least a 2 hour notice. For clients with pet insurance, we are happy to provide you with the necessary information/diagnosis to submit a claim to your insurance carrier, submission forms are to be acquired and submitted by the client. If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your animal. By signing below, you agree to the foregoing terms of payment:Client/Owner Signature*Date* MM slash DD slash YYYY Client/Owner Name (Please Print) First Last Animal NameBreed¹Subject to credit approvalNameThis field is for validation purposes and should be left unchanged.
