Client Intake Form

Save time during your upcoming appointment! Before your arrival, fill out the necessary documents online at any time from any device.

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MVMC No-Show Policy

The health and well-being of our patients is our number one priority at Maine Veterinary Medical Center (MVMC) and we pride ourselves on our ability to see your pet in a timely manner. We understand that at times, unforeseen circumstances may arise, resulting in the inability to keep a scheduled appointment, however, in this instance we request you inform our office as soon as possible so that we may offer that spot to another patient in need. In the event you do need to cancel an appointment, we will happily reschedule you for our next available appointment slot with the applicable specialist. In the interest of fairness to both you and our staff, if you do not show up for two consecutively scheduled appointments or cancel these appointments in less than 48 hours of the appointment time, you will be asked to pre-pay the consultation fee prior to scheduling a third time.

CLIENT INFORMATION

Primary Contact *

First

Last

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

Pronouns

Primary Phone Number *

Secondary Contact

First

Last

(Any other names on your account go here)

Pronouns

Secondary Phone Number

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Physical Address (if different than above)

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Preferred method for appointment reminders *

Email
Text

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 Date of Birth *

Primary Contact Initials *

PATIENT INFORMATION

Patient Name *

Layout

Breed *

Color *

Primary Veterinary Hospital *

Secondary Veterinary Hospital *

Pet Insurance

Disclaimer: MVMC only accepts direct payments from Trupanion and Healthy Paws

Layout

Company Name

Policy Number

Please consent or declide 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, American Express, Care Credit and personal checks. A deposit of 50% of the signed estimate is required for all patients upon admission to the hospital.

There is a $25 returned check fee on any check returned for insufficient funds.

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

Signature *

Date *

Client Intake Form

MVMC No-Show Policy

CLIENT INFORMATION

PATIENT INFORMATION

Pet Insurance

Contact Maine Veterinary Medical Center

Address

Phone

Email

Hours