Estimate Request Form

Treatment Plan Request Form

Thank you for trusting us to care for your pets! Please fill our this form with as much information as possible. We will create a treatment plan based on the information you provide and the services you are interested in.
IMPORTANT:

Requesting a treatment plan does not schedule an appointment for your pet. Treatment plans are used to create recommendations and financial expectations prior to your visit. All treatment plans are an estimate and are subject to change based on your pet's unique needs. Please allow 48 hours for us to respond to your request. We look forward to serving you!
Have you ever brought a pet to Hog Mountain Animal Hospital?*

YesNo
Owner's Name*

First NameLast Name
E-mail*
Phone Number:*

Area CodePhone Number
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How did you hear about us?*

Google (or other search engine)FacebookInstagramIs there someone we can personally thank for your referral?
Please tell us who we may thank for your referral!

Pet's Name*
Species*

DogCat
Date of Birth/Age of Your Pet*
Breed & Color*
Sex*

MaleNeutered MaleFemaleSpayed Female
Which treatments or procedures are you interested in? *
We will provide you with pricing details, treatment options, and other information for each service you are interested in.
Do you Already Have a Scheduled Appointment?*

YesNo
Appointment Date

MonthDayYear
Date
Appointment Time

:HourMinutesAM/PM Option
Is your pet up to date on vaccines?
Previous Veterinarian(s)
If none, please let us know that!

Client Policies and Procedures

We want you to be aware of and understand the following policies and procedures for all clients.
I agree to release Hog Mountain Animal Hospital from all claims for libel, slander, invasion of privacy, infringement and copyright or right of publicity or any other claim and confirm that you are over the age of 18 years old. (initial below)*
Initial
TREATMENT CONSENT:

By signing this document, I declare I am the lawful owner of all listed pets and all information is true and correct to the best of my knowledge. I hereby authorize the veterinarian(s) of Hog Mountain Animal Hospital to examine, prescribe for or treat my pet(s) to the best of their abilities. I assume responsibility for all charges incurred in the care of this animal. I acknowledge that medical information will not be released to anyone not indicated on this form without my express verbal and/or written permission with the exception of another veterinary facility.
FINANCIAL POLICY:

Our office accepts Visa, Mastercard, American Express, and Discover. We also accept cash and checks (only with verification of valid driver's license or other ID at time of payment).

In addition, we also offer 3rd party financing options for our clients via Care Credit. We accept a variety of Care Credit plans based on the total transaction amount for your pet. Care Credit requires that payment only be made for services as they are rendered, we cannot charge services to your account in advance. Additionally, the use of Care Credit requires that the card be present every time and that identification is verified. We appreciate your understanding of our desire to protect your account/identity.

As financing options are offered, we cannot offer additional in-house payment plans for our services. Clients needing additional financial support are encouraged to apply for Care Credit with a co-signer.

Full payment is due at the time of service. This includes any charges/fees agreed to by my authorized proxy. Our team is happy to provide any client with a written treatment plan prior to services being rendered.
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Should be Empty:

Treatment Plan Request Form

IMPORTANT:

Client Policies and Procedures