Southtowns Animal Hospital Client Information Form

*Please Note this form is ONLY for clients that have an account already created with us. If you have not been to our practice before and would like to establish a veterinary-client-patient relationship please call the office BEFORE filling out the client information form to start your account.*

Thank you for giving us the opportunity to care for your pet. Please help us better meet your needs by taking a few moments to fill out this information sheet.

Owner's Name(s):

First NameLast Name

Address

Street Address Line 2

CityState

Zip

Main contact phone number? This is the number we will always call first

Format: (000) 000-0000.

Best phone number to text?

Format: (000) 000-0000.

Secondary phone number (text or call)?

Format: (000) 000-0000.

Preferred contact method for follow-ups, medication pick-ups, etc. *Preferred contact method will be used whenever possible. In cases involving urgent or important medical concerns, we may contact you by phone regardless of preference* :

Email Address

example@example.com

Driver's License #

Employer's Name & Address

Is there anyone else you would like authorized to make medical decisions for your pet? Spouse? Family? Other?

Is there anyone else you would like to authorize to make medical decisions for your Pet? Spouse? Family? Other? This authorization is for ALL medical decisions including but not limited to emergency situations and end of life care.

If YOU have an emergency at our office, who should we call?

Name of Emergency Contact

Phone Number for Emergency Contact:

Format: (000) 000-0000.

Name of Previous or Current Veterinarian

How did you hear of our hospital?

Other

Name of individual or business referral:

To help prevent the spread of infectious diseases, ALL hospitalized animals must be current on all vaccines.

I understand every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital and handling. I hereby authorize this hospital to receive, prescribe for, treat or perform surgery upon the pet(s) listed on the reverse side. Furthermore, I agree to pay fees for services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated. I agree to pay for the reasonable costs of collection in the event that collection efforts become necessary.

Vaccine Consent: (This must be signed if you would like us to vaccinate your pets)

I chose to have my pet(s) vaccinated according to the veterinarian's recommendations. I understand and accept that uncommon side effects can occur such as: vomiting, diarrhea, facial swelling, hives, difficulty breathing, autoimmune diseases, sudden collapse, and death. I accept these as noted risks with all vaccines. In addition, I understand that for the health and safety of humans, my pets vaccine information will be released if need be to any State/Federal organizations, groomers, or other animal hospitals. My personal information such as my phone number and address will not be released.

Date

Thank you for choosing Southtowns Animal Hospital. Our primary mission is to deliver the best and most comprehensive veterinary care available for your pet. An important part of the mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options. Southtowns Animal Hospital requires payment in full at the end of your pet's examination and/or at the time of discharge.

We will gladly prepare a written treatment plan if you so desire. Please ask the receptionist or doctor.

Professional fees are due at time services are rendered.

Payment Options:

Cash
Visa, Mastercard, Discover
Care Credit
- Additional Information for CareCredit:
  - Allows you to begin treatment today and pay over time. Available for any treatment amount.
  - Pay for health, and wellness care at over 225,000 enrolled providers across the nation. Once you've applied, you can use it again and again at any location that accepts CareCredit.
  - With short term financing option of 6 months no interest is charged on purchases of $200 or more when you pay the full amount due by the end of the promotional period. If you do not, interest is charged from the original purchase date.*
    *Subject to credit approval.

***At this time, we do NOT accept checks or American Express***

For some treatments or hospitalized care, a deposit is required. Any pets admitted to the hospital will be required to leave a deposit of 50% of the estimated treatment plan. Healthcare plans requiring comprehensive care of more than $300 or more, will require a 50% deposit to begin your pet's treatment.

Additional Policy Information: Southtowns Animal Hospital charges $49 for returned checks. For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance.

Waiting Room Policy: I understand that I am responsible for my pet while visiting Southtowns Animal Hospital. This includes keeping them safe and out of harms way. I will keep my pet on a leash in the hospital and in the parking lot. If my pet cannot be on a leash, they will be in an appropriately sized pet carrier.

Email Policy: I understand that if I give my email address to Southtowns Animal Hospital, it may be lionked to other services. Other services may be the hospital's online pharmacy, VetSource, or our cremation service, Final Gift Pine Rest Pet Cemetery. If your pet has an adverse reaction to vaccines or medication, your email may be given to companies that produce those products, Boehringer Ingelheim, Elanco, Zoetis, or Merck.

No Show and Cancelation Policy: Every time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. Clients who fail to show for their appointment or do not notify the office within 24 hours of their scheduled appointment time, shall be subject to a $55 No Show and Cancelation Fee. In the event of an actual emergency, consideration will be given, and a one-time exception may be granted.

If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your pet.

By signing below, you agree to the foregoing terms of payment: I certify that I am the owner of the animal listed below, and I have the authority to execute this consent.

Date

Print Owner Name

Pet(s) Names

Please include the names of ALL the pets on your account

Southtowns Animal Hospital

Financial Policy