New Client Information Form

Thank you for giving our hospital the opportunity to care for your pet. So that we may create an account for you and a chart for your animal, please take a moment to complete the following.

Section 1: Owner info

OWNER:

CO-OWNER:

Contact Email Address (required):

ADDRESS:

PHONE:
(In an effort to keep you informed of your pet’s status we must have at least two phone
numbers where we can reach you or an emergency contact person. Thank you for your
cooperation.)

If necessary, may we call you at work? YesNo

Employers name: Work Number:

How did you first hear of us? Yellow PagesSignInternetOther
Referred by:

Section 2: Patient information & history

Pets Name: Sex: MaleFemale

Spayed / Neutered?: YesNo

Species:DogCat

Breed:

Color/Markings:

Approximate date of birth or age of pet now: Todays date:

Any previous serious illness or surgeries?

Any allergies to vaccinations or medications?

Is your pet on any special diet or medications?

Do you feed your pet table scraps or bones? How Often?

Section 3: Payment

Do you have pet insurance today? YesNo
How will you be paying for today's services? CashCheckCredit CardCare Credit
CA driver's license or CA I.D. number:
exp:

ABBY PET HOSPITAL PAYMENT POLICY

The staff at Abby Pet Hospital is devoted to providing you and your pet with the best
veterinary care possible. To allow us to focus on this important job and remain effective
and efficient, we have adopted the following policy concerning payment for our services.

1. Payment is expected when services are rendered.

2. We accept cash, checks (with proper I.D.), Visa, MasterCard, Discover, American
Express, and Care Credit. In an effort to protect you, we will not accept credit card
payment over the phone. You must be present at our office and have a valid I.D.

3. We offer billing for unexpected costs through Care Credit only. Care Credit is a
separate lending company and clients must qualify and be approved for this credit
plan. Our clients must apply for this credit plan prior to payment and will find out if
their credit is approved within 15 minutes in most cases. All billing requests through
Care Credit should be addressed to them to allow our staff to focus on treating your
pets. If interested, ask a receptionist how to apply for Care Credit.

4. Pet insurance is accepted for approved procedures.

Please do not discuss fees and billing with your veterinarian. Your veterinarian is there to service the needs of your pet and others; our veterinarians are not authorized to make billing or credit arrangements. Fees and billing are handled by our credit managers, not by the veterinarians. We do not offer independent payment plans through our hospital.

Section 4: Informed Consent

I certify that I am over 18 years of age and will assume responsibility for all charges incurred in the care of this pet. I understand that FULL PAYMENT IS DUE AT THE TIME SERVICE IS RENDERED AND THAT A DEPOSIT OF 50% OF MY BILL MUST BE PAYED FOR ANY HOSPITALIZED PET. If full payment is not made as required, Abby Pet Hospital has my permission to obtain credit information from an authorized agency to assess my credit worthiness to aid in collection.


Owner/responsible party:
Date:

Leave A Comment

*
*