New Client Form


Welcome to the Veterinary Resource Center.  The VRC is a low-cost clinic developed to offer veterinary services to owners with financial need.  If you are not in need of financial assistance, we encourage you to use your own veterinarian, as we strive to offer our discounted veterinary services to community members in need.  The Veterinary Resource Center is only open Monday through Friday from 8 am until 4:30 pm.  If you find that you need emergency care after the VRC closes or if there are no available appointments, you will need to seek alternative care at another veterinary clinic or emergency clinic.

 

Please fill out the following information so we can verify your information.

Name(s):  

Street Address:  

City:  

State:  

Zip:  

Email: 
(Note: that we only use email to confirm appointments and for the Doctor to discussion lab results)

Cell Phone:  

Home Phone:  

Alternate Contact:  

Phone:  

Would you like your alternate contact listed on your account?

 

 

Animal Name:  

Age:  

Breed:  

Coat Color:  

Sex:

Spayed/Neutered:    

 

Animal Name:  

Age:  

Breed:  

Coat Color:  

Sex:

Spayed/Neutered:  

 

Animal Name:  

Age:  

Breed:  

Coat Color:  

Sex:  

Spayed/Neutered:  

 

Animal Name:  

Age:  

Breed:  

Coat Color:  

Sex:  

Spayed/Neutered:  

I grant permission to Veterinary Resource Clinic to examine, perform diagnostic testing and prescribe appropriate treatment for my pet(s).  I understand that I am responsible for payment for services rendered for my pet(s).  I have authority to make medical decisions for this pet including euthanasia decisions.

AGREEMENT TO RELEASE AND WAIVE LIABILITY, HOLD HARMLESS, INDEMNIFY AND ASSUME RISK OF INJURY OR LOSS

I understand that my use of HSHA’S VETERINARY RESOURCE CENTER is not without risk to my pet(s).

These include, without limitation, risks of physical injury, exposure to disease, and contact with other animals.  All risks are known and appreciated by me.   I waive any and all specific notice of the existence of the risks.  I agree that I am solely responsible for my pet’s behavior and agree communicate behavior concerns to HSHA.  I acknowledge that HSHA reserves the right to terminate any in-progress or future visits on the basis of dog to dog aggression, dog or cat to person aggression, or person to person aggression.

By reading, signing and dating this document, I hereby waive, release and hold harmless HSHA, and/or its employees, agents and volunteers, from any and all damages, losses, fines, claims, suits, expenses (including attorney fees and defense costs), judgments, and/or liabilities of any form or nature resulting from any act or omission at HSHA.  This release of liability includes, but is not limited to, any injury, death, sickness, or personal injury or property damage my pet or I may incur.

By my signature below, I hereby state that I fully understand and agree to the above terms and conditions in consideration for the services provided by the HSHA’S VETERINARY RESOURCE CENTER.

Leave this empty:

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Signature Certificate
Document name: New Client Form
lock iconUnique Document ID: f568a17b0fd1d4ab185e58b5a55d05c771732289
Timestamp Audit
July 16, 2020 12:09 pm EDTNew Client Form Uploaded by Humane Society of Harrisburg Area - noreply@humanesocietyhbg.org IP 50.76.113.117
July 17, 2020 5:07 pm EDTAmanda Brunish - amandab@humanesocietyhbg.org added by Amanda Brunish - amandab@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
July 23, 2020 12:50 pm EDTAmanda Brunish - amandab@humanesocietyhbg.org added by Amanda Brunish - amandab@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
July 23, 2020 12:52 pm EDTAmanda Brunish - amandab@humanesocietyhbg.org added by Amanda Brunish - amandab@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
July 23, 2020 12:55 pm EDTAmanda Brunish - amandab@humanesocietyhbg.org added by Amanda Brunish - amandab@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
July 23, 2020 12:56 pm EDTAmanda Brunish - amandab@humanesocietyhbg.org added by Amanda Brunish - amandab@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
July 23, 2020 1:00 pm EDTAmanda Brunish - amandab@humanesocietyhbg.org added by Amanda Brunish - amandab@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
July 23, 2020 1:00 pm EDTAspasia Yeager - aspasiay@humanesocietyhbg.org added by Amanda Brunish - amandab@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
July 27, 2020 2:43 pm EDTAmanda Brunish - amandab@humanesocietyhbg.org added by Amanda Brunish - amandab@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
July 27, 2020 2:43 pm EDTAspasia Yeager - aspasiay@humanesocietyhbg.org added by Amanda Brunish - amandab@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
August 4, 2020 11:29 am EDTAmanda Brunish - amandab@humanesocietyhbg.org added by Humane Society of Harrisburg Area - vetresources@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
August 4, 2020 11:29 am EDTAlisha Klase - alishak@humanesocietyhbg.org added by Humane Society of Harrisburg Area - vetresources@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
August 4, 2020 11:30 am EDTNoelle Weeks - noellew@humanesocietyhbg.org added by Humane Society of Harrisburg Area - vetresources@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
August 4, 2020 11:38 am EDTAmanda Brunish - amandab@humanesocietyhbg.org added by Humane Society of Harrisburg Area - vetresources@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
August 4, 2020 11:38 am EDTAlisha Klase - alishak@humanesocietyhbg.org added by Humane Society of Harrisburg Area - vetresources@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
December 9, 2020 2:41 pm EDTNoelle Weeks - noellew@humanesocietyhbg.org added by Humane Society of Harrisburg Area - vetresources@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
December 9, 2020 2:41 pm EDTShania Davis - shaniad@humanesocietyhbg.org added by Humane Society of Harrisburg Area - vetresources@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
February 11, 2021 3:05 pm EDTNoelle Weeks - noellew@humanesocietyhbg.org added by Humane Society of Harrisburg Area - noreply@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
February 11, 2021 3:05 pm EDTShania Davis - shaniad@humanesocietyhbg.org added by Humane Society of Harrisburg Area - noreply@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
August 24, 2022 4:09 pm EDTNoelle Weeks - noellew@humanesocietyhbg.org added by Humane Society of Harrisburg Area - noreply@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
August 24, 2022 4:09 pm EDTShania Davis - shaniad@humanesocietyhbg.org added by Humane Society of Harrisburg Area - noreply@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
August 24, 2022 4:09 pm EDTMegan McKinney - meganm@humanesocietyhbg.org added by Humane Society of Harrisburg Area - noreply@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
September 22, 2022 2:39 pm EDTNoelle Weeks - noellew@humanesocietyhbg.org added by Humane Society of Harrisburg Area - noreply@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
September 22, 2022 2:39 pm EDTShania Davis - shaniad@humanesocietyhbg.org added by Humane Society of Harrisburg Area - noreply@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
September 22, 2022 2:39 pm EDTMegan McKinney - meganm@humanesocietyhbg.org added by Humane Society of Harrisburg Area - noreply@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
September 22, 2022 2:41 pm EDTNoelle Weeks - noellew@humanesocietyhbg.org added by Humane Society of Harrisburg Area - noreply@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
September 22, 2022 2:41 pm EDTShania Davis - shaniad@humanesocietyhbg.org added by Humane Society of Harrisburg Area - noreply@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
September 22, 2022 2:41 pm EDTMegan McKinney - meganm@humanesocietyhbg.org added by Humane Society of Harrisburg Area - noreply@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
November 4, 2022 3:14 pm EDTNoelle Weeks - noellew@humanesocietyhbg.org added by Humane Society of Harrisburg Area - noreply@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
November 4, 2022 3:14 pm EDTMegan D - megand@humanesocietyhbg.org added by Humane Society of Harrisburg Area - noreply@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
November 4, 2022 3:14 pm EDTMegan McKinney - meganm@humanesocietyhbg.org added by Humane Society of Harrisburg Area - noreply@humanesocietyhbg.org as a CC'd Recipient Ip: 50.76.113.117
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