Owner's Name

First Middle Last

Home Phone

Work Phone

Cell Phone

What is your preferred method of contact?*

Phone

Spouse/Partner/Co-Owner's Name

First Middle Last

Home Phone

Work Phone

Cell Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

How did you learn of our hospital?*

Who can we thank?*

What social media platforms do you use?

Other

Other information the office should know?

FINANCIAL POLICY:

Our office accepts Visa, Mastercard, Discover and Care Credit, along with cash and checks (only with current DL information on file). Full payment is due at the time of service. Clients with payment concerns are asked to speak to a Client Service Representative before their exam. Our staff is happy to provide any client with a written treatment plan prior to services being rendered. Client will be responsible for a 1.5% monthly finance charge on accounts over 30 days and any collection fees on accounts over 90 days. As of September 1, 2015, we offer 6 months, no interest financing via Care Credit for clients in need a credit plan. No other payment plans are offered at this time. Your signature below indicates your agreement with this policy.

TREATMENT CONSENT:

I hereby authorize the veterinarian to examine, prescribe for or treat the below-described pet(s) to the best of their abilities. I assume responsibility for all charges incurred in the care of this animal. I acknowledge that medical information will not be released to anyone not indicated on this form without my express permission.

We love social media! Do we have your permission to share your pet(s)’ image and story on social media, our website & other forms of related media?*

Yes

Signature

Date

Pet 1

Pet's Name

Species

Breed

Color/Markings:

Vaccinations were last given by (clinic name)

Allergies or Long-term Medical Problems:

Birth Date

Sex

Male

Female

Spayed/Neutered?

Yes

Not sure

Color

Do you have a second pet?

Yes

Pet 2

Pet's Name

Species

Breed

Color/Markings:

Vaccinations were last given by (clinic name)

Allergies or Long-term Medical Problems:

Birth Date

Sex

Male

Female

Spayed/Neutered?

Yes

Not sure

Color

Do you have a third pet?

Yes

Pet 3

Pet's Name

Species

Breed

Color/Markings:

Vaccinations were last given by (clinic name)

Allergies or Long-term Medical Problems:

Birth Date

Sex

Male

Female

Spayed/Neutered?

Yes

Not sure

Color

Do you have a fourth pet?

Yes

Pet 4

Pet's Name

Species

Breed

Color/Markings:

Vaccinations were last given by (clinic name)

Allergies or Long-term Medical Problems:

Birth Date

Sex

Male

Female

Spayed/Neutered?

Yes

Not sure

Color

Do you have a fifth pet?

Yes

Pet 5

Pet's Name

Species

Breed

Color/Markings:

Vaccinations were last given by (clinic name)

Allergies or Long-term Medical Problems:

Birth Date

Sex

Male

Female

Spayed/Neutered?

Yes

Not sure

Color

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