Curbside Registration Form- Easton

Curbside Registration Form

Tell us about yourself!
Easton Animal Hospital staff ask that you please wear a mask when we interact with you at your car as we are helping bring in and return your pet to you. It is so important that we stay healthy so we can continue to help you and your pet.
Owner *

First Name Last Name
Co-Owner/ Secondary Contact

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone Number *

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number
Email *
example@example.com
Please enter the date and time of your scheduled appointment with us: *

Month Day Year
Date Hour Minutes AM/PM Option
How did you hear about us? *
If other, where did you hear about us?
Have you brought this pet to our facility before? *

Yes No
Since we need to come to your car, please list the following information about your vehicle: Make, Model, Color *
What phone number should we use to contact the person who is bringing your pet (if not you)? *

Area Code Phone Number

COVID-19 Acknowledgement
For the protection of both our team and clients, have you been exposed to COVID-19 or know anyone who has or is currently showing symptoms? *

Yes- We can still see your pet! We have the ability through teleconferencing to be able to see your pet safely. Please download the Zoom application through the Google Play Store or Apple Store and give us a call! No
Have you traveled outside the United States of America or the state of Ohio within the last 2 weeks? *

Yes No
I understand that to help decrease the spread of possible contaminants, my pet's personal items, including but not limited to: collar, leash, carrier, cages, pet clothes, blankets, muzzles, etc. may remain in the vehicle and I allow Easton Animal Hospital to use their own items to transport and restrain my pets. *

Accept

Curbside Registration Form

CPR Consent
Should my pet require CPR (Cardiopulmonary Resuscitation), including but not limited to cardiac compressions, positive respiration, emergency medications, or other heroic interventions, I consent that the doctors at Easton Animal Hospital are given my permission to conduct such medical care.

I also understand the following:
- I agree to be financially responsible for all veterinary services provided to my pet while Easton Animal Hospital team members pursue treatment.
- I understand that regardless of my pet’s recovery or survival I agree to pay the CPR fee in addition to other fees already identified by the practice and agreed upon by me.
- I understand that despite the best efforts of the doctors and team members, CPR may not be successful.
By typing my signature on the bottom of this page, I understand this to be my expressed written consent to accept or decline CPR services. *

Accept Decline
Signature *

Clear

Curbside Registration Form

Financial Policy
I understand the following about Easton Animal Hospital’s financial policy:
- Payment is required at the time of service.
- Services are NOT eligible for billing at any time.
- Failure to pay will result in balance transfer to collections IMMEDIATELY.
- If an account is sent to collections, an administration fee, collection fee, and billing fee will be added to the balance.
- Third party payment will only be valid if required proofs of identity are acquired.
By typing my signature on the bottom of this page, I understand this to be my expressed written consent to accept Easton Animal Hospital's financial policy. *

Accept
Signature *

Clear
I will be paying today by: *

Debit/Credit Cash Care Credit I need to talk to a Client Service Specialist
Please call us at (614) 476-0000 when you pull into our parking lot. Be prepared to answer your phone and please do not leave our parking lot. Our doctor will go over a treatment plan with you. After receiving payment, we will return your pet to you.
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Curbside Registration Form