Access Veterinary Care | Master Client Form

Client Info
Visit Reason
Health Checklist
Specific Questions
Wellness/General
Policy Agreement

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Welcome! We use this multi-purpose smart form for all our appointments to sure things don't get missed and your pets get the best care possible, so we do ask you to fill it out at each visit. However, it's SMART, so it will be VERY short if you've been in recently and don't have new concerns!

I am a: *

New/First Time Client (Welcome!)

Returning AVC Client (Welcome Back!)

What can we do for you? *

Request New Appointment

I have an appointment - just need to fill out the pre-visit history.

Add a new pet (congrats!)

IMPORTANT: New client appointments are often booked a couple of weeks out; if you have an urgent need please call us to check availability prior to filling out this form.

Virtual Care

Is this pet a current Wellness Member? *

Yes

Virtual care options are only available to Wellness Member pets; please deselect Virtual Care and choose another option above.

Do not continue with this form, you will be unable to submit.

AVC offers convenient Virtual Care options for our Wellness Members, including full consultations with our doctors, Case Review for straightforward questions, and some specific convenient options to help with things like noise phobia or anxiety at the groomer.

Currently this uses a separate form, which can be found here: www.accessvetcare.com/virtual-care

Do not continue with this form, you will be unable to submit.

Basics

Your Name (First) *

Last Name *

Pet Name: *

Email *

When was this pet last seen at AVC? *

Do you currently carry insurance on this pet? *

Yes

Name of Insurance Company *

Would you like to release records to this insurance company at their request? *

Yes, release any requested records to the above insurance company

No, contact me for instructions/approval

Note: We are happy to provide complete medical records to your insurance company on request and with your approval. All records are considered complete and final; no information or paperwork beyond this will be provided to them.

Phone *

Have any of your pets been seen at AVC in the past two years? *

We look forward to meeting you (or seeing you again)! We'll just need to update your client info below to make sure everything is current.

Which AVC office do you prefer? *

New Client Info

Phone Number *

Is this a mobile number that can receive texts? *

Address *

Apartment Number

City *

Zip Code *

Is there another person you'd like listed on the account? (Clarifying the relationship is useful, but not necessary)

How did you hear about us? * How did you hear about us?

Please let us know who so we can thank them!

If your family has any serious allergies, please let us know:

Important Info for New Clients

Both offices are only a few minutes apart and operate as one, as do our staff. During busy periods first appointments for new clients may be unavailable for 1-2 weeks, and/or limited to our larger New Albany office (though once established clients may request either office if available).

A non-refundable $25 deposit is required to book your first appointment. If canceled or rescheduled with less that 48 hours notice the deposit may be forfeit. This reduces no-shows and last-minute cancellations to improve timely access to care for our patients.

NOTE: New patients with significant prior medical history, a Diagnostics and Records review fee of $35-55 may be required in addition to Exam & Consultation costs. This is not an issue for most new patients, but should be expected for "second opinion" visits or patients with chronic or multiple existing issues, due to the time required for thorough DVM review of prior records and testing .

I have read the above.

Are there new problems/concerns since that visit?: *

Yes

Species: *

* Answer determines follow-up questions.

How old is your pet? *

LESS than 1 year

1 - 6 years

* Answer determines follow-up questions.

Mobility issues are common in older pets, and may not be obvious. Would you like to answer a few additional questions to assess your pet?

Yes

Breed (or best guess!): *

Color/Markings *

Sex: *

Age (or best guess): *

Birthdate (if known):

Adoption Date: *

Important - if your account may be under another person's name, please list them here so we can find you:

Have a favorite picture? Add it to their chart here. You can also just email it to us later.

Maximum file size: 1MB

What veterinary office last vaccinated or examined your pet? *

Contact your prior veterinarian in advance of your visit to obtain records

Email to records@accessvetcare.com, fax to 812 590-3083, or drop off in person.

If records of vaccinations or diagnostics are not provided prior to your appointment, it may be necessary to repeat them.

NOTE for new patients with significant prior medical history: A Diagnostics and Records review fee of $35-55 may be required in addition to Exam & Consultation costs. This is not an issue for most new patients, but should be expected for "second opinion" visits or patients with chronic or multiple existing issues, due to the time required for thorough DVM review of prior records and testing .

Text

Do you need to go ahead an setup an appointment? *

Yes

No, we don't need an appointment (or have already set one up)

Appointments

Virtual Care

Basics

New Client Info

Contact your prior veterinarian in advance of your visit to obtain records