Owner's Name (First and Last Name)
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E-mail address
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner's Cell Phone Number
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Owner's Home Phone Number
Work phone number
Preferred Contact Method
Please Select
Phone call
Text message
Email
No preference
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
Please Select
Phone call
Text message
Email
No preference
How did you become aware of our clinic?
*
Please Select
Previous client
Google
Facebook
Yelp
Website (www.ecv.vet)
Yellow pages
Sign/Building
Friend/Family Referral - who may we thank
Other
Pet information
Pet's name
*
Age or Birth Date
*
Species
*
Please Select
Canine (dog)
Feline (cat)
Avian (bird)
Rabbit
Breed
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Sex
*
Please Select
Female
Female Spayed
Male
Male Neutered
Unknown
Color
*
Microchip
*
Please Select
Yes
No
Maybe
What medical problems should we be aware of?
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Previous veterinary clinic (Name, City, State, Date of last visit)
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Permissions
Previous Medical Records: I hereby give permission to East Central Veterinarians to obtain previous medical records for the above listed patient.
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I AGREE
Decline
No previous veterinary care
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.
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I AGREE
Decline
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.
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I AGREE
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.
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I AGREE
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.
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I AGREE
Legal Responsibility: By signing below I assume full legal and financial responsibility for the above listed pet.
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I AGREE
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.
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I AGREE
Signature
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Submit
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