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New Client Information
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Email *
Accepted Forms of payment
We accept Cash, Check, Debit, and Credit Cards (subject to 3% surcharge). We are also now accepting Care Credit with optional flexible financing (www.carecredit.com). If you'd like to know more about care credit, please ask reception when you are scheduling or visit their website at carecredit.com/go/768SFB
Will you be attending the Diet & Nutrition Course BEFORE your first appointment? *
Thank you for your interest in our clinic. We are excited to work with you to give your furry companion the healthiest life through holistic veterinary care, client education and support to optimally elevate your pet's quality of life. On a scale of 1-5  how much do you know about holistic medicine and veterinary care? *
Please answer for the PRIMARY CLIENT. If applicable, secondary client information is towards the end of the form.
First name: *
Last name: *
Email for sending receipts and plans: *
Street Address *
City *
State *
Zip code *
Phone Number? *
I allow Balance Veterinary Care to contact me through text messages
How did you hear about Balance Veterinary Care?
Clear selection
If referred, who was the client/provider? (if no referral it's okay to write N/A)
Past Vet Clinic?
Would you like to add a second person to your account? *
Second person first and last name:
Second person email:
Second person phone number:
Pet Information
Please send a current photo through text (541)343-5028 or email info@balancevc.com for their medical record.
What is your pet's name? *
Canine or Feline? *
Sex?
Clear selection
Breed? (your best guess is okay) *
Color? *
Birth date or Best Guess of Age? *
Weight? (estimate is okay) *
Known Allergies? *
Why are we seeing your pet? *
Is this your first pet?
Clear selection
What sorts of days/ times work best for you?
Mornings 9:15am- 11:30am
Early Afternoons 12pm- 2pm
Afternoons 2pm- 4pm
Other: share details below
Mondays
Tuesdays
Wednesdays
Fridays
Saturdays
What kind of appointment are you looking to schedule? Dr. Wright charges for her time regardless of the appointment type.
Clear selection
How would you like to be contacted? (If you are planning to have a phone consultation or mobile appointment we need to call you to get payment information on file)
 *
Which Clinic last saw your pet? *
Medical Records
Please send any records to info@balancevc.com or fax them to (541)653-8828
Pet History
If this is your first appointment for this pet with our team, please share as much as you are able regarding your pet's history. (If we have this information from a previous appointment, feel free to move on to the Current Health section.)
Where did you pet come from and when did you acquire them?
Please share about your pet's life experiences.
Has your pet had any surgeries?
What treatments worked or not?
Current Health
Please share as much as you are able regarding your pet's current health condition(s).
What is your pet's current diet? Treats? (brand/homemade/ ingredients, quantity)
 *
What are the current supplement and/or medications your pet is taking? What are the doses?
 *
Is your pet experiencing any upset stomach symptoms and or changes in their stool? (throwing up any fluids/hairballs/food/etc) *
Required
Does your pet show signs of allergies? (itching/hot spots) *
Mild
Moderate
Cyclical (reoccurring every few months to a year)
Chronic (doesn't go away)
None
Itching
Hot spots
Ear Redness/inflammation
Paw licking/chewing
How is your pet's mouth? *
Required
Please list any specific behavioral concerns your pet has. (ie: nervous, aggressive, etc.) *
Goals for your Appointment
What are your main concerns today? *
Do you have any lab tests you would like done during this appointment? *
Anything else you would like us to be aware of for your pet?
 *
Cancellation Policy: A minimum of 48 hours notification is required. If the required is not met, a cancellation fee will be applied. Late Cancellation/No Show Fees: $50 for a doctor appointment. $20 for a vet assistant appointment. A $5 Non Refundable Deposit is required at the time of scheduling. This will be applied to the final cost of your appointment. Please be prepared to provide your card information at that time. Thank you!
*
By typing my name, I agree I have read, understand, and will follow this policy:
Clinic Contact Information
Thank you for filling out our new client form. Before you submit this form please add this number to your contacts. This is our direct line and it accepts calls and text messages: (541)343-5028. Thank you!

To bypass our call tree here are the numbers:
1. Reception - **this is the only line that will ring.**
2. Supplement Order - direct to voicemail
3. Food Order - direct to voicemail
4. Practice Manager - direct to voicemail
5. Vet Assistant or Dr Teri Sue - direct to voicemail
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