Forms – Monticello Pet Hospital

New Patient Form

Owner's Name
Name*
First Last
Day-Time Phone*
Email*
Enter Email Confirm Email
Pet Information
Pet's Name*
Species*
or if other species
Breed (if known)
Color
Date of Birth or Age (if known)
Special Identification (tattoo, microchip, etc.)
Sex
Previous Veterinary Practice (if any)
Previous Veterinarian (if any)
Date of last vaccines (if known)
Date Format: MM slash DD slash YYYY
What vaccines were given at this time
Is your pet on any medication or supplement?
- Yes
- No
If Yes, please list the medication or supplement
What food does your pet eat?
Does your pet have allergies or drug reactions?
- Yes
- No
If Yes, please list the allergies and reactions
Are there any current or past medical conditions of which we should be aware?
- Yes
- No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Please use the following box to give us any other relevant information about your pet

Financial Policy & Confidentiality Form

Financial Policy
Thank you for choosing Monticello Pet 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. Monticello Pet Hospital requires payment in full at the end of your pet's examination and/or at the time of discharge.

Payment Options:

You can choose from:

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

- Convenient Monthly Payment Plans¹ from CareCredit® & Scratchpay (Subject to credit approval) This will allow you to begin treatment today and pay over time, available for any treatment amount.

Additional Policy Information:

Monticello Pet Hospital charges $30 for returned checks. For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier.
Confidentiality and Nondisclosure Release*
The Monticello Pet Hospital considers all information obtained from its clients as fundamentally private. In the course of everyday practice, however, there are occasions that require the release of information. This form is to alert you to your innate right to privacy of information, but a release for us to disclose information in the following situations:
- Yes, I give the Monticello Pet Hospital authority to transfer records to another pet care facility via fax or ground currier for diagnostics, referral or vaccination verification.
- Yes, I give the Monticello Pet Hospital authority to give out vital statistics from my records in an effort to reunite me with my pet were it ever lost or stolen.
- o No, I do not give the Monticello Pet Hospital authority to release any information from my pet records.
Authorization*
- I hereby authorize the Monticello Pet Hospital Veterinarian to examine, prescribe for, or treat my pets. I assume responsibility for all charges incurred in the care of the pets listed on my account. I have also read and completed the Confidentiality and Nondisclosure Release Form as well as the Financial Policy Form.
Name*
Date*
MM
DD
YYYY

Breeding Agreement

Anesthesia & C-Section Consent Form

Anesthesia and Surgery Consent Form

Prescription Refill and Food Order Request Form

Please use the form below to request your prescription refill or food item. This will save you time when picking up your order. Please allow 24 hours for order processing. Do not come to the clinic until you have received confirmation to pick up your order.

Note: Some prescriptions will require an examination of your pet prior to re-filling.

Many prescriptions require your pet to be examined before dispensing. This ensures that your pet is healthy enough to handle the potential side effects of some prescriptions and provides further confirmation that the medication is appropriate for your pet’s current condition.

IMPORTANT: Prescription Refills and Food Orders are not confirmed until you have received notification. A staff member will contact you by phone or email.

Name*
First Last
Email*
Phone*
Pet Name*
Drug or Food Name*
Dosage
Size
Strength
Quantity*
Additional Comments*

Our Forms

New Client Registration Form

Owner's Name

Co-owner's Name & Contact #

Pet Information

New Patient Form

Owner's Name

Pet Information

Client Change Form

New Co-Owner

Pet Update

Financial Policy & Confidentiality Form

Financial Policy

Breeding Agreement

Anesthesia & C-Section Consent Form

Anesthesia and Surgery Consent Form

Prescription Refill and Food Order Request Form

Travel Certificate Questionaire

New Clients

Pet Health