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Client Agreement Form

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Client Agreement Form

Please fill out this form completely.

Completion of this form will be required for continued care at Woodhaven Animal Health.

This form will take approximately 10 minutes to complete.


This form will review our various policies to include:

  • Understanding the appropriate veterinary-client-patient relationship
  • Emergency and urgent care status
  • 24-hour care status
  • Payment agreement
  • Late arrival appointments & missed appointments
  • Return of prescription medications
  • Media release

Please read each section below thoroughly and completely.

AGREEMENT INFORMATION The information provided in the agreement will help Woodhaven Animal Health better serve your needs, along with those of your pet(s). Please enter your first and last name(s) as it appears on your account at Woodhaven Animal Health.
Name(Required)
UNDERSTANDING THE VETERINARIAN-CLIENT-PATIENT RELATIONSHIP (VCPR)
  • The Veterinary-Client-Patient relationship (VCPR) is a legal standard set forth by the State of Wisconsin regulatory board along with the American Veterinary Medical Association.
  • A valid VCPR is established when the client and patient have appropriate in-person interactions in a timely manner with the veterinarian and veterinary staff. This interaction includes the client coming to the clinic for annual examination of the patient, along with recommended follow-up examinations and appropriate diagnostics, based on specific medical need(s).
  • The client may further interact with the veterinarian and the staff by telephone and e-mail. In rare instances, the veterinarian or veterinary staff may visit the home of the client in order to care for the patient.
  • The veterinarian and staff are responsible for maintaining medical records to document examinations, diagnostics, recommendations, and follow-up care for each patient.
  • Prescription medications cannot be prescribed and specific advice may not be given if the VCPR is not current.
Agreement(Required)
EMERGENCY & URGENT CARE STATUS
  • Woodhaven Animal Health is not an emergency care clinic nor an urgent care facility.
  • We are not available for consultation outside of our regular business hours.
  • During regular hours, our ability to see urgent or emergency cases on a particular day is based on our current case load, along with the availability of our staff.
  • If we have reached our maximum capacity for the day, the staff will advise you to seek care at one of the urgent care or emergency facilities out of respect for our previously scheduled clients and the time limits of our staff.
  • The closest urgent and emergency care facilities are: BluePearl Hospital - Appleton, BluePearl Hospital - Green Bay, PAW Health Network - Mosinee, Madison Veterinary Specialists - Madison, and UW Veterinary Care - Madison.
  • We encourage you to contact one of these facilities for availability prior to arrival at their building.
  • These facilities will share their medical records with Woodhaven Animal Health after your visit is completed in order to allow us to provide continued care, when necessary.
  • Please be aware that there is often a delay of several days before we receive records, and in some cases, we are never notified of a patient’s visit; as such, it is beneficial for you to to notify Woodhaven Animal Health if you have had such a visit to one of these facilities so we can follow-up.
Agreement(Required)
24-HOUR CARE STATUS
  • Our veterinary clinic is NOT a 24-hour care facility and we do not provide 24-hour monitored care.
  • During the overnight hours from 5:30 pm to 7:00 am, your pet will not be monitored by an individual if there is the need for your pet to remain at our clinic overnight.
  • If your pet is deemed to be in a critical condition, we will advise that you transport your pet to a local 24-hour facility.
  • If you do not consent to leaving your pet without overnight observation and you decline transfer to a local 24-hour care facility, you may choose to take your pet home even though it may be against our professional recommendation.
Agreement(Required)
PAYMENT AGREEMENT
  • Payment for services is to be rendered prior to patient discharge from the clinic.
  • Valid payment forms include cash, check, VISA, MasterCard, Discover and Care Credit.
  • Woodhaven Animal Health will not store payment information, including credit or debit card numbers.
  • Funds must be available at the time of service when paying by check or debit card.
  • In the case of a check being returned due to non sufficient funds, you will assume financial responsibility of the original check amount and the bank’s returned check fee of $25. You will also forfeit the ability to pay by check again in the future.
  • Failure to rectify unpaid invoices as a result of a returned a check may result in forwarding the account to a collections agency and/or termination of the veterinarian-client relationship. Furthermore, services will not be provided if there is an outstanding balance on the account.
  • In rare circumstances, Woodhaven Animal Health may allow for a promissory note for a balance due with scheduled payments (this is at the sole discretion of the veterinary staff of Woodhaven Animal Health).
Agreement(Required)
LATE ARRIVAL & MISSED APPOINTMENT POLICY
  • With the heightened demand for veterinary services, every appointment slot is valuable to us and our patients. Missed appointments are times when a sick pet could have received medical care, and late arrivals can have a domino effect for the remaining clients scheduled for the day.
  • MISSED APPOINTMENT: If a client fails to appear for their previously scheduled appointment or surgery, we will require a deposit equal to the cost of the expected services for every future appointment or surgery. If the client and patient fail to appear for a subsequent pre-paid appointment or surgery, the client will forfeit the full pre-payment. After 3 missed appointments or surgeries, the client will not be allowed to receive future care from Woodhaven Animal Health and we will send a notification of client termination.
  • LATE ARRIVAL: Late arrivals for appointments of greater than 5 minutes may cause the veterinary staff to arrive late for the subsequently scheduled appointments on a given day. The staff already has the challenge of managing unexpected emergencies and medically complex appointments that may run beyond the time allotted on the schedule, so additional delays need to be avoided. If you know you will arrive late, please call the clinic on your way so we can all plan accordingly.
  • When a late arrival occurs, we will either offer to see your pet, offer to have your pet admitted for a “day care” (which requires you or a designated party to return prior to the close of business for your pet), or we will offer to reschedule your appointment. The option offered will be up to the veterinary staff based on the flow of the appointment schedule on the given day. Repeatedly late arrivals may result in termination of the client from Woodhaven Animal Health for all future care.
  • At Woodhaven Animal Health, we realize that our clients are occasionally kept waiting beyond their scheduled time. We truly strive to prevent this from occurring, but between late arrivals, complex cases, concurrent emergencies and/or staffing shortages, we cannot always guarantee the start time for an appointment. If we are taking longer to start your appointment than your schedule allows, please notify the receptionist and we will offer to admit your pet for “day care” or reschedule your appointment as soon as possible.
  • We understand that emergencies arise and schedules change, so please contact us as soon as possible if you are unable to appear for your already scheduled appointment or surgery.
Agreement(Required)
RETURN OF PRESCRIPTION MEDICATION
  • A request to return a pharmacy item for refund must be approved by the veterinary staff on a case-by-case basis.
  • A returned pharmacy item may incur a restocking fee up to 25%.
  • Liquids are typically not accepted for return.
  • Prescriptions and supplements may be donated to the clinic for use by another patient in need.
  • We do not accept “sharps” for disposal under any circumstance.
Agreement(Required)
MEDIA RELEASE
  • Woodhaven Animal Health may photograph and/or video record my pet(s).
  • Woodhaven Animal Health may post images and/or video recordings of my pet(s) to the clinic website, Facebook , Instagram, and/or other social media platforms.
  • Woodhaven Animal Health may use images and videos for marketing and/or educational purposes.
Agreement(Required)
UNDERSTANDING OF CURRENT AGREEMENT
  • I acknowledge that I / we have completely read and fully understand all of the above information and agree to be bound thereby.
  • I / we understand that failure to comply may result in no longer being able to seek care for my pet(s) at Woodhaven Animal Health.
  • I understand that I/we must complete and return this form to Woodhaven Animal Health within 7 days of receipt to receive a $ 5.00 account credit for your compliance.
Agreement(Required)
Clear Signature
MM slash DD slash YYYY
Thank you for your cooperation in helping us to maintain our commitment to excellence.
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