New Client Form/ Payment Policy

North Ogden Animal Hospital

1580 N. Washington Blvd. Ogden, UT. 84404 801-782-4401
Name

First Name Last Name
Spouse or Partner

First Name Last Name
Does this person have authorization to make medical decision including euthanasia

Yes No
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Cell Phone

Area Code Phone Number
Email * Your email address will be used for reminders, Petly, and our online store.
example@example.com
Referred by a Friend? Who can we thank?
Appointment Date

Month Day Year
Date
Name of Pet
Breed
Pet's date of birth or age
Species
Color
Gender

Female Male Spayed Female Neutered Male
Medical conditions
Medication(s) currently giving
Additional Pets: Name, Age, Breed, Gender, Color
Payment is due at time of services. For your convenience we accept:

Cash, Check, Visa, Mastercard, Discover, American Express, Care Credit and Scratch Pay.
Authorization for examination, treatment, photos and assumption of financial responsibility.

I hereby authorize the veterinarian to examine, prescribe for and/or treat the above described pet/pets. I assume reponsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment. To prevent the spread of infectious diseases and parasites, hospitalized animals must be current on all vaccines. Any photographs taken of my pet along with my name may be used in electronic or printed material for publicity or advertising purposes.
Signature

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Date

Month Day Year
Date
Our Payment Policy

We value you as a client and appreciate the trust you have in us to provide quality care for your pet.

To avoid any confusion over payment concerns, please take a moment to review our payment policy.

Payment is expected for services at the time they are provided. Any non-emergency services such as neuters, spays, dental procedures, cosmetic surgery, etc. must be paid in full at the time your pet is released to you. A deposit of at least 50% is required when your pet is admitted to our hospital for emergency treatment or major surgical procedures.

To keep our expenses and your fees to a minimum, we cannot extend credit.

Our hospital accepts cash, personal checks, Care Credit, Scratch Pay, debit cards, VISA, MasterCard, American Express and Discover cards as payment. Any returned checks go directly to our collection agency.

Scratch Pay and Care Credit are medical credit cards that we make available to our clients. Most applicants with a good credit history will be accepted. Applications can be processed at the time of the office visit or can be made at scratchpay.com or www.carecredit.com even before services are provided.

We always encourage our clients to ask for an estimate and discuss charges before a pet receives medical services. We will do our best to provide as accurate an estimate as possible. Treatment of your pet is determined by your decisions, with consideration of your financial resources. You have the right to decline any or all treatment recommended for your pet.

Again, thank you for choosing us to care for your pet!

North Ogden Animal Hospital
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North Ogden Animal Hospital