Welcome to West Hills Animal Hospital! Thank you for giving us the opportunity to care for your pet(s). In order for us to serve you better, please take the time to fill out this form completely.

Client Information

Name *

First

Last

Spouse/Co-Owner

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Primary Phone *

Secondary Phone

Co-Owner Phone

Do you live within Knoxville’s city limits? *

Yes
No

May we text or email you vaccination and appointment reminders? *

Yes
No

AUTHORIZATION OF TREATMENT & FINANCIAL OBLIGATION

I hereby authorize the veterinarian at West Hills Animal Hospital PLLC, to examine, prescribe for, and treat my pet(s). Any animal admitted or hospitalized shall receive the necessary diagnostic tests and treatment to ensure proper medical care. I agree to pay for all services rendered and medications, goods, and supplies when purchased. I understand that a deposit may be required for surgical or medical treatment. ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.

By my signature below, I hereby agree to all of the above and acknowledge the receipt of a copy of this agreement (upon request).

Signature *

Clear Signature

Date *

PHOTO RELEASE

West Hills Animal Hospital maintains an internet and public relations presence for marketing & client education purposes. May we use/post photographs of your pet(s) and/or family? We would refer to pets and people pictured by first name only, if at all.

Please indicate your preference by selecting ONE of the following: *

WHAH has my permission to use or post photographs of my pet(s) and/or family
WHAH has my permission to use or post photographs of my pet(s) and/or adult (18+ years old) family members ONLY
WHAH has my permission to use or post photographs of my pet(s) ONLY
WHAH may NOT use or post photographs of my pet(s) and/or family

Patient Information

Pet's Name *

Age/Date of Birth *

How long have you owned this pet? *

Species (dog, cat, etc.) *

Sex *

Male
Neutered Male
Female
Spayed Female

Breed *

Color/Markings *

Any allergies to vaccines or medications?

Any previous surgeries or serious illness?

Is your pet on any special diet or medications?

What food does your pet eat? *

My pet lives: *

Indoors only
Mostly indoors
Indoors/Outdoors
Outdoors only

Do you have other pets in your household? If so, what species and how many?

Previous Veterinarian

Date of Last Vaccines

What vaccines were given?

APPOINTMENT SCHEDULING POLICY

Thank you for giving West Hills Animal Hospital the opportunity to care for your pet(s). Based on the information you give us when scheduling your appointment, we try to set aside enough time to provide you with the highest quality care. Should you need to cancel or reschedule an appointment, kindly contact our office as soon as possible and no later than 24 hours prior to your scheduled appointment time. This gives us enough time to schedule other patients who may be waiting for an appointment.

Our Appointment Cancellation Policy is below:

New Clients

New clients are required to place a one-time deposit of $62.50 to schedule their first appointment. This deposit is refundable only if the appointment is cancelled or rescheduled prior to 24 hours before the appointment time. The deposit will not be refunded if the appointment is cancelled or rescheduled within 24 hours of the appointment time.

Existing Clients

Established clients who fail to keep an appointment without giving 24-hours notice will be charged a $35 fee and may be required to make a non-refundable deposit of the office exam when re-scheduling. Repeated “no shows” will result in the client being dismissed from the practice.

Surgical and Dental Procedures

A 10% deposit based on the procedure’s estimate (or $62.50, whichever is greater) shall be required to schedule surgical/dental procedures. This deposit is refundable only if the appointment is cancelled prior to 48 hours before the appointment time. The deposit WILL NOT be refunded if the appointment is cancelled or rescheduled within 48 hours of the appointment time.

As a courtesy, we send reminder emails for appointments. If no email is on file, we call if time allows. If you do not receive a reminder, the above policy will remain in effect.

We understand there may be times when an unforeseen emergency arises, and you may not be able to give appropriate cancellation notice. Our Practice Manager may waive the Late Cancellation fee under these circumstances. You can contact West Hills Animal Hospital 24 hours a day/ 7 days a week at (865) 357-1270. Outside of normal business hours, you may leave a message on our voicemail. Messages left are an acceptable method of cancellation.

I have read and understand the above appointment cancellation policy and agree to its terms. *

I have read and understand the above appointment cancellation policy and agree to its terms.

Signature *

Clear Signature

Date *

YOUR PET’S PRESCRIPTIONS

Our in-house pharmacy is an integral part of our hospital, and the income derived from it helps carry part of the practice overhead. We rely on pharmacy income to pay salaries, utilities, taxes, insurance, and other expenses related to operating the practice. EVERY time a medication is requested, your pet’s medical record is reviewed by a veterinarian prior to approval; thus, ensuring that state and federal laws governing dispensing medications are followed, that the proper medication is given at the proper dosage, and that your pet’s healthcare needs are being met to the highest standard.

We understand, however, that the convenience and pricing of other pharmacies may be better suited for some of our clients. To that point we provide the following options for obtaining prescription medication for your pets.

Our in-house pharmacy: We strive to provide competitive pricing, rebate information, and a quick turnaround.
VetSource and Chewy: Both online pharmacies provide us with a small compensation for our time and efforts and we can initiate the request while you are in the office. Chewy and VetSource integrate with our practice software and allow for streamlining and transparency in requesting, checking the status of, and refilling prescriptions through a trusted source. They are also sources for medications that we do not carry on-site, such as compounded medications, and food items.
Written prescriptions: ALL written prescriptions, prescriptions called into or faxed to a pharmacy, and ALL controlled drug prescriptions will incur a $15.50 charge. This charge is not a penalty, but rather covers the cost of overhead inherent in processing these requests. We will strive to maximize refills to lower your costs and minimize the need for us to review the request.

If you have any questions regarding the above policy, please do not hesitate to ask. We understand this is different from human medicine and we truly want you to be properly informed so that you can decide on the best way to obtain your pet’s medications. As always, we appreciate you allowing us to be a part of your pet's health care team.

I have read and understand the above policy and agree to its terms. *

I have read and understand the above policy and agree to its terms.

Signature *

Clear Signature

Date *

PERMISSION TO RELEASE/OBTAIN MEDICAL RECORDS

The Tennessee Board of Veterinary Medical Examiners states in Rule 1730-01-.13(6) that client records can only be released with the written permission of the client (with the exception of law enforcement, state & federal agencies & courts of law). The TBVME has stated that this includes requests for vaccination records from boarding facilities, groomers and other veterinarians. For further information please see the TBVME’s Policy statement regarding release of Patient records at Board of Veterinary Medical Examiners–TN.gov website.

Permission To Release/Obtain Medical Records *

I DO hereby give permission to West Hills Animal Hospital to release or obtain my pet(s) medical records. Furthermore, I realize that any change to this authorization must be made in writing.
I DO NOT authorize the release of any of my pet’s medical records to any facility unless further permission is granted in writing.
I DO NOT authorize West Hills Animal Hospital to obtain my pet’s medical records unless further permission is granted in writing.

Signature *

Clear Signature

Date *

West Hills Animal Hospital

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Client Information

AUTHORIZATION OF TREATMENT & FINANCIAL OBLIGATION

PHOTO RELEASE

Patient Information

APPOINTMENT SCHEDULING POLICY

Our Appointment Cancellation Policy is below:

YOUR PET’S PRESCRIPTIONS

PERMISSION TO RELEASE/OBTAIN MEDICAL RECORDS

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