Client Information

Primary Contact *

First

Last

(Primary Contact information will be used to locate your account)

Pronouns

Primary Phone Number *

Primary Email *

Secondary Contact

First

Last

(The Secondary Contact will be able to make decisions for your pet in case we can't get in touch with the Primary Contact)

Secondary Email

Pronouns

Secondary Phone Number

Mailing Address (Primary Contact) *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Physical Address (if different than mailing address)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Preferred method of contact *

Text
Email

Primary Contact Date of Birth

Due to our compliance with the Maine Prescription Monitoring Program, by providing your date of birth you are consenting to a prescription search that is mandatory when prescribing certain medications.

Primary Contact Initials (Verifying Correct DOB) *

Clear Signature

Patient Information

Patient Name *

Date of Birth/Age *

Species

Breed *

Color *

Sex *

Female Intact
Male Intact
Female Spayed
Male Nutered

Are you making an appointment at the request or guidance of your pet's veterinarian? *

Yes
No

If yes, who is the referring hospital? *

If Other *

If no, who is your primary hospital? *

If Other *

Who is the referring veterinarian? *

If Other *

Do you have a secondary veterinarian/hospital your pets goes to?

If Other *

Pet Insurance

Pet Insurance Disclaimer: MVMC only accepts direct payments from Trupanion

Company Name

Policy Number

Please consent or decline to use of any pictures/videos taken at MVMC on our multimedia accounts.

I consent
I decline

Please read carefully below:

I, the owner of the pet listed above, understand that payment is due upon completion of services. MVMC does not offer any payment plan options. MVMC does accept Visa, MasterCard, Discover, American Express, Care Credit, ScratchPay, and Affirm Loans. As of March 1, 2024, we no longer accept personal or business check payments. All money orders and bank-issued checks will continue to be accepted. A deposit of 50% of the signed estimate is required for all patients upon admission to the hospital.

A 1.5% monthly interest charge will be placed on balances left with MVMC.

If my account remains unpaid and sent to collections, MVMC reserves the right to add 50% of the balance due to the existing account for the cost of collection.

I have read the above information and agree to abide by these conditions

A 1.5% monthly interest charge will be placed on balances left with MVMC.

If my account remains unpaid and sent to collections, MVMC reserves the right to add 50% of the balance due to the existing account for the cost of collection.

I have read the above information and agree to abide by these conditions

Initials *

Today's Date *

Signature *

Clear Signature

Please type "I am not a robot" for quality assurance

Client Intake Form

Client Information

Patient Information

Pet Insurance

Contact Maine Veterinary Medical Center

Address

Phone

Email

Hours