Maine Veterinary Referral Center - Online Referral Form

Client Information Online Form

Making your appointment

If this is your first visit, please arrive 10 minutes before your scheduled appointment time to process paperwork.
Confirm health records and diagnostic results needed for MVRC appointment
Let our receptionist know if you will need assistance bringing your pet into the building from your vehicle so that we can be ready to assist you.
If you or the MVRC anticipates that your pet will be admitted for hospitalization, you may want to bring special diets and medications.
Please label all items with your pet’s name.

Please have your vet fax or email any health records or diagnostic images relating to your pet’s case.

Date:
Owner / Agent
Telephone Number
Cell Number:
Address:
Street Address, State. Zip Code
E-mail:
Employer:
Address of Employer:
Occupation:
Work Telephone Number:
Owner Soc. Sec. #, if paying by check
Spouses / Co-Owners Name:
Spouses Address, if different:
Spouses / Co-Owners Home Telephone
Spouses / Co-Owners Work Telephone
Pet' Name:
Species:
Breed:
Sex		Male Female
Spayed / Neutered:		Yes No
Weight:
Does your pet have any known critical conditions or Allergies:
Date Vaccine was Given: Distemper / Parvo:
Date Vaccine was Given: Rabies:
Date Vaccine was Given: Lyme:
Date Vaccine was Given: Bordetella
Referring Veterinarian:
Referring Veterinarian Hospital and Phone:
Current Medications:
Date Symptoms Started:
Problems or Symptoms Observed:
ACKNOWLEDGEMENT/CONSENT I, the agent of the pet listed above, verify that the above information is true. Furthermore, I acknowledge: that if for any reason the Maine Veterinary Referral Center is left with an unpaid balance on services rendered that I will be subject to a 1 ½ % monthly interest charge on that balance. If my account remains unpaid and is sent to collection, the Maine Veterinary Referral Center reserves the right to add 50% of the balance due to the existing account. If a credit card number is left for a deposit and a balance remains for 10 days after services are provided, the remainder of the account will be placed on the credit card.
Signature: ___________________________________
If possible, please fill out the online client form before your appointment. When you arrive to MVRC for your appointment, we will confirm this information with you and ask you to sign the agreement/consent. Thank you
Office Use Only – Account Number

Please fill out the on-line client form. When you arrive at MVRC, you may sign this form. Thank you