Lake Seminole - New Client Form

1
New Client Form* This field is required.
Owner Name
Co-Owner Name
Email
Phone
2
Pet Information* This field is required.
Pet Name
Breed
Sex
3
Referral? How did you get our contact information?
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In case of an emergency when you cannot be reached, who is authorized to make important decisions or consent to procedures/treatments for your pet?* This field is required.
Emergency Contact Name
How may we contact this person in an emergency?
5
I authorize Lake Seminole Animal Hospital to perform such diagnostic, therapeutic and surgical procedures as are in their opinion, necessary and advisable for treatment and maintenance of my animal’s health and well being. The nature of such procedures has been described to me to my satisfaction. While I expect all procedures to be done to the best of the abilities of the professional staff, I realize that neither guarantee nor warranty can ethically or professionally be made regarding results or cure. I authorize the hospital director and his team to provide veterinary service as requested or in emergency circumstances to follow through with such procedures as necessary for my pet on a continuing basis until further advised.* This field is required.
Initial
6
I consent to release a copy of my pet’s medical records and information to other veterinary or specialty care facilities when such information is relevant and directly related to my pet’s current medical care as deemed necessary by the veterinarian.* This field is required.
Initial
7
I understand payment of fees is requested at time of service, release or termination of the case. I understand that I should not hesitate to ask for estimates before services are initiated. I understand interest will be charged at the maximum amount allowed by law on any outstanding balance. If I have a balance for more than 90 days, my account will be forwarded to a collection agency and may be reported to the credit bureau. In that event, I agree to pay a 20% collection fee, plus attorney’s fees and court cost in addition to the balance owed.* This field is required.
Initial
Should be Empty: