Phone: (219) 879-0249  -  

1943 S Woodland Ave, Michigan City, IN 46360
Mon, Tue, Thu, Fri: 7:30AM-5:00PM
Wed: 7:30AM-7:00PM
Sat: 7:30AM-Noon

Woodland Veterinary Center

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Client-Patient Information Form

"*" indicates required fields

Client-Patient Information Form
Thank you for giving us the opportunity to care for your pet(s). Please help us meet your needs better by taking a few moments to complete each of the information sheets.
MM slash DD slash YYYY
Owner's Name*
Co-Owner's Name
Address
Preferred Method of Contact*
How did you first hear of our hospital?

Pet Information #1

Species*
Sex*
Date of last Vaccines & Clinic done at
Vaccine
Date
Clinic
 

Pet Information #2

Species
Sex
Date of last Vaccines & Clinic done at
Vaccine
Date
Clinic
 

Pet Information #3

Species
Sex
Date of last Vaccines & Clinic done at
Vaccine
Date
Clinic
 

Notification/Agreement

To prevent the spread of infectious diseases and parasites, hospitalized and medical boarded animals must be current on all vaccines and free of internal and external parasites. I authorize the Woodland Veterinary Center to provide vaccines and parasite control as needed for my pet. I am financially responsible for the patient(s) described above and agree to pay all fees incurred. I understand that any medical or surgical procedure is attended by some risk and that it is not possible to guarantee that successful outcome of any such procedure. This agreement is in force indefinitely from this date unless notify Woodland Veterinary Center in writing on the contrary.

Authorization for release of medical records

I authorize the Woodland Veterinary Center to acquire any and all medical or surgical records from my previous veterinarian and /or send such information to any veterinarian and/or pet boarding/ grooming facility as requested by us or them.

Appointment Cancellation/ Late & Reschedule Policy Agreement

Woodland Veterinary Center is committed to providing all of our patients with exceptional care. When a patient cancels without giving enough notice, they prevent another patient from being seen.

If you need to reschedule an appointment, please give our office a call at 219-879-0249 the day prior to your scheduled appointment to notify us of any changes or cancellations. If after 2 missed/canceled appointments, you will be charged a deposit before scheduling another appointment. If you miss/cancel that appointment your deposit will be forfeited and another deposit will be required to schedule another appointment.

If you are more than 10 minutes late to your scheduled appointment you will be asked to reschedule the appointment or you will be seen as a work in (work in can mean anytime from your original appointment to the time we close) and be charged a work-in fee.

PHOTO CONSENT

I grant to Woodland Veterinary Center, its representatives and employees the right to take photographs of me/ or my pet, and to copyright, use and publish the same in print and or electronically. I agree that Woodland Veterinary Center may use such photographs of me and or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content.*

Payment Information

  • Payment is due in full at the time services are rendered
  • This office does NOT do any billing, we do NOT offer payment plans
We accept the following forms of payment:
  • Visa
  • MasterCard
  • Discover
  • American Express
  • Care Credit
  • Cash
  • Scratchpay

We accept personal checks with a valid Driver’s License or Social Security Number. There is a $25 fee for all returned checks.

Please print and sign below that you are taking responsibility for full payment of treatment and services for the pets you are bringing into Woodland Veterinary Center, at the time they are treated. If you are not the individual who is financially responsible for these pets, by signing this form you are stating that you have made prior arrangements with the individual who is. I agree to absolve, veterinarian, and staff employed by the practice of any financial consequences that may occur between you and the other individual you have made prior arrangements with.

MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.

CONTACT US

Information

  • Woodland Veterinary Center
  • (219) 879-0249
  • 1943 S Woodland Ave, Michigan City, IN 46360
    Mon, Tue, Thu, Fri: 7:30AM-5:00PM
    Wed: 7:30AM-7:00PM
    Sat: 7:30AM-Noon
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    • Acupuncture
    • Veterinary Orthopedic Manipulation
    • Dentistry
    • Microchipping
    • Pain Management
    • Radiology
    • Senior Care
    • Ultrasound
    • Veterinary Cold Laser Therapy
    • House Calls
    • Nutritional Counseling
    • Parasite Prevention
    • Surgery
    • Vaccinations
  • Contact
  • Appointments
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