PATIENT INFORMATION

Mountainview Animal Hospital

Alan J. Topal, DVM, P.C.

And Associates
Name *

First Name Last Name
Address *

Street/Number/PO Box Address

Street Address Line 2

City
State: *
Zip: *
Primary Phone Number: *
Significant Other Name/Phone Number:
Email Address:
(Email address for Pet Portal access, Vaccine & Appointment reminders by email)
PATIENT INFORMATION
Pet's Name: *
Breed: *
Color: *
Date of Birth: *

Month Day Year
Date
Female/Male *
Spayed/Neutered *
Vaccine History (Please provide proof of rabies vaccination or one will be administered):
Any Health Concerns:
How did you hear about us?
Date of first appointment: *
I understand by signing below, if a significant other has been listed, you are giving them permission to authorize treatment to any animals listed on your account in your absence.

ALL PAYMENTS ARE DUE UPON COMPLETION OF VISIT.
Please specify method of payment below (Check/Cash/Credit Card): *
Signature: *

Clear
Date: *

Month Day Year
Date
FINANCIAL POLICY
Effective open communication and understanding of practice fees and financial policies are vital elements in establishing and maintaining an ongoing professional relationship between you—the client—and us the veterinarians. We want you to understand what you are paying for and the true value of the professional veterinary services that we offer your animals. Some of our fees are predictable and can be quoted fairly accurately prior to seeing a patient. Others, such as those calls requiring emergency services or extensive diagnostic procedures, can only be estimated. We encourage you to ask whichever attending veterinarian you are seeing about the anticipated costs of these necessary procedures beforehand, as to avoid any misunderstandings with respect to the invoice generated.

As the veterinarians at Mountainview, we try to be available and willing to serve your emergency veterinary needs Monday – Friday from closing until 8pm. While some people may consider this availability just part of what it means to be a veterinarian, it is not without great personal effort and sacrifice by our families that we undertake this great obligation to our patients and their owners. As a small business, we have obligations to banks, creditors, suppliers, utility companies, our support staff, and state/federal/local taxation. The only way that we can meet these obligations, continue to provide excellent veterinary services, acquire and pay for new equipment and inventory, and update our skills and stay current through continuing education and additional training, is through following sound business practices. A big part of maintaining a healthy small business is ensuring a steady cash flow. Accounts owing to us from past veterinary work performed may appear fine on paper, but these anticipated funds owed to Mountainview from clients do not pay the current bills. Simply put, we expect timely payment for timely services rendered. This is the only way our small business can operate and survive. It is out of absolute necessity that we outline and enforce the financial policy below.

Client/Patient Form: A fully completed form must be in our files in order for veterinary care to be performed (routine or emergency) on a patient. The information gathered on any and all forms submitted by the client will be strictly confidential and will only be used for the purposes of accurate record keeping and for our billing practices. Those clients wishing to provide us with their e-mail address can be assured it will only be used for reminders, coupons and/or special updates.
Payment of Fees:
Fees are payable at the time of the service rendered. We would like to devote our time to caring for your animal(s), as opposed to managing our billing accounts. We accept payments by cash, checks, Visa, MasterCard, American Express, Discover and Care Credit. Please note that certain invoices may not yet include totals for things like courier fees or additional laboratory tests requested. Once we have received invoices for these services, these additional costs will be sent to the client as a separate invoice at a later date.
Partnerships:
Listing any additional person(s) in the spouse/significant other area of our registration form gives them permission to treat any animals on your account in your absence. In the event you decide to remove them from your account at any time, the NYS Veterinary Board requires us to ask for written permission from person(s) to do so.

Billing to Account: Unfortunately at this time, billing on accounts is not permitted.
Returned Checks:

A fee of $30.00 is charged for each check returned for non-payment.
Insured Patients:
We do not bill insurance companies. It is the owner’s responsibility to pay for veterinary work carried out, insurance, examinations, etc. We will provide you with the appropriate paperwork to supply to your insurance company.
Receipts: Receipts/invoices will be given to the client at the time of service.
Collections/Overdue Accounts: We are unable to perform additional veterinary work or dispense any medications for clients who have overdue accounts receivable. Such accounts will either be turned over to collection agency or other legal actions may be undertaken to receive those funds.

If you would like a copy of this financial agreement, we would be happy to give you a copy.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

PATIENT INFORMATION

FINANCIAL POLICY

Payment of Fees:

Partnerships:

Returned Checks:

Insured Patients:

Receipts: Receipts/invoices will be given to the client at the time of service.