ECV - New Patient Admission Form

Owner's Name (First and Last Name)

E-mail address

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Owner's Cell Phone Number

Owner's Home Phone Number

Work phone number

Preferred Contact Method

Employer

Spouse/Significant Other/Co-Owner's Name (First and Last Name)

Spouse/Significant Other/Co-Owner's Cell Phone

Spouse/Significant Other/Co-Owner's Employer

Spouse/Significant Other/Co-Owner's Work Phone

Spouse/Significant Other/Co-Owner's Preferred Contact Method

How did you become aware of our clinic?

Pet's name

Age or Birth Date

Species

Breed

Sex

Color

Microchip

What medical problems should we be aware of?

Previous veterinary clinic (Name, City, State, Date of last visit)

Previous Medical Records: I hereby give permission to East Central Veterinarians to obtain previous medical records for the above listed patient.

Photograph Release: I hereby give permission to East Central Veterinarians to take photographs of my pet and use my pet's name and photographic likeness in printed and/or electronic media.

Authorization and consent for services: I verify that all information contained in this document is correct and current. I will notify East Central Veterinarians of any changes to my contact or ownership information. I authorize that I am the owner of this patient, that I am at least 18 years of age and that I have the authority to authorize medical care for this pet - surgery, diagnostics, treatments, and euthanasia – to be performed by East Central Veterinarians.

Medical Records Release: I give consent to release medical records for this patient. We will still ask for verbal authorization and a reason for transfer of records. This is for protection of your privacy and security of legal medical information.

Payment for all services are due at time of services performed: I understand that I am financially responsible for all services rendered. A deposit may be required for certain medical or surgical procedures. The hospital accepts payment by Cash, Visa, MasterCard, Discover, American Express, CareCredit, and Scratchpay. A $35.00 service fee will be applied to all returned checks. Any unpaid balance will be charged interest at a per annual rate of 8% compounded on a monthly basis. Additionally, if any portion of the payment is received after the payment due date as set forth above, then a late payment fee of $5 shall be due each month the balance remains unpaid. I understand that if the balance is not paid in a timely fashion, I will be responsible not only for the balance due, but any collection agency fees, court costs, and/or attorney fees that are incurred in the attempt to collect this debt. In the event a collection agency is hired to collect any outstanding amount, you agree to pay a collection fee in the amount of 35% of the outstanding balance.

Legal Responsibility: By signing below I assume full legal and financial responsibility for the above listed pet.

Electronic Signature: By selecting the "Submit" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.

Signature

Pet information

Permissions