Patient History Form

Date*

Client Name*

First NameLast Name

Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Secondary Contact Name

First NameLast Name

Secondary Contact Number

Please enter a valid phone number.

How did you hear about us?

Patient Name:*

Species:*

Breed:*

Color:*

Age or Date or Birth*

Patient Gender*

Who was your pet seeing before Continental Animal Wellness Center? (Please have the previous facility send your pet's records to info@mycawc.com)*

Please list your pet's current medications and strengths:*

Reason for your pet's visit:*

Any further history that may be important about your pet:

FINANCIAL POLICY AND AGREEMENT

At Continental Animal Wellness Center, we strive to practice exceptional medicine and surgery for both small and large patients. Only if we receive prompt payment for our services and products can we continue to provide the uncompromised care that our clients and patients expect and deserve.

1. For the convenience of our clients who seek to provide the best for their animal’s health and comfort, our animal hospital approves of several convenient methods of payment:

Cash, CareCredit Financial Services, Checks, Credit Card (All Major Credit Cards) Pet Health Insurance

2. We will review a cost estimate with you in advance of all surgical procedures or non-routine workups. We want you to feel comfortable discussing your financial responsibilities with us, so we can help you maximize the care of your pet.

3. All fees for services or products must be paid at the time of service.

4. No additional services may be charged to any accounts with outstanding balances past 30 days due. Emergency cases for clients with delinquent accounts will be taken only after arrangements for payment in full are made.

5. For all NSF checks returned from the bank there will be a $50 returned check fee.

6. Balances left unpaid after 30 days will incur a $25 service fee in addition to a 10% finance charge monthly. Any balances over 90 days are considered delinquent and turned over to The Collection Agency. Should any delinquent amount be submitted to collections, an amount equal to 33% of the total invoice will be added to the balance to cover any collection fees. In the event a suit is filed, the client will be liable for all reasonable attorney fees and court costs.

"The undersigned understands and agrees upon all that is listed above and that any amount due for services are payable at the time of service.”

Signature*

Date *

SOCIAL MEDIA CONSENT

I hereby authorize Continental Animal Wellness Center to take photographs or produce videotapes, audiotapes, electronic files, or other types of media productions that capture my pet’s name or image, to be released to members of the media, or to be used by Continental Animal Wellness Center for the purpose of: News media (online, print and/or broadcast), websites and social media, publications and/or promotional materials, and medical and/or educational training. Your name and personal information will remain confidential.

Signature

Date