Lincolnway Veterinary Forms Welcome Form Name * Name First First Last Last Email * Location - We are located at 4019 Lincolnway East in Mishawaka, IN. We are in the Twin Branch area near the Lincolnway & Bittersweet intersection. We just want to make sure there is no confusion on our location - we are NOT the clinic near the airport * I am aware of your location and it works for me! Oops! I thought you were located somewhere else. Please cancel my appointment. To ensure we have adequate time to care for all patients on the day of your appointment, we ask that you arrive at your appointment 10 minutes early. If you are running late, please call and let us know - then, when you arrive we will discuss options to best serve you and your pet. * I Understand Lincolnway Veterinary Clinic has a No Call, No Show/Cancellation Policy that is as follows - We require 24 hour's notice for any canceled appointments. Due to the amount of patients we are serving, our appointment times are very valuable. If you are unable to make your appointment and do not give us proper notice a fee equivalent to the price of the exam will be assessed on the account and must be paid before we can reschedule. * I Understand If you are receiving this form then you have booked a new client appointment with us. Our new clients are required to pay a $81 deposit for an exam. If you reschedule your exam with at least 24 hours notice your deposit will transfer with your appointment. If you cancel or reschedule your appointment without 24 hours notice you will lose your deposit. If you are rescheduling without 24 hours notice you will need to pay an additional $81 deposit to move your appointment. * I understand this policy. Spouse or Secondary Owner of Pet. Spouse or Secondary Owner of Pet. Please note that the spouse or secondary owner of your pet will be able to make decisions on your pet's behalf and can only be removed from your account by the Primary Owner. Please note that the spouse or secondary owner of your pet will be able to make decisions on your pet's behalf and can only be removed from your account by the Primary Owner. Spouse or Secondary Owner of Pet. Address * Address This is important for legal documents related to your pet's health and wellness, such as rabies certificates and licenses, etc... This is important for legal documents related to your pet's health and wellness, such as rabies certificates and licenses, etc... Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Primary Phone Number * This phone number should be the phone that is easiest to reach you when called. Please include if this number is a work, home or cell phone number. Secondary Phone Number Driver's License Number * Please bring your driver's license with you to the appointment. Name of Employer * Employer Phone Number * Full Name of Representative and Phone (with area code) in the case of an EMERGENCY * Please check this box if this person is authorized to make decisions regarding your pet in the case of an EMERGENCY. This person is authorized How did you hear about us? * Website/Online Sign/Drive-by Social Media Newsletter Advertisement/Radio Fundraiser/Public Event Friend or Family Member Commercial OtherOther If you are human, leave this field blank. Next
