New Patient Form

Name*

First NameLast Name

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number*

Please enter a valid phone number.

Home Phone Number

Please enter a valid phone number.

Pet Name*

Species of Pet*

CanineFelineOther

If you selected "other" as species of your pet. Please specify below. *

Breed of pet*

Sex of Pet*

Male UnalteredMale Altered (Neutered)Female UnalteredFemale Altered (Spayed)

Age or Date of Birth*

Color*

Financial Policy

Macon County Veterinary Hospital requires payment in full at the end of your pet's examination and/or a the time of dishcarge.

Payment Options: You can choose from:
- Cash, Check, Visa®, MasterCard®, Discover Card®, CareCredit®
, and Scratchpay®
- Convenient Monthly Payment Options¹ from the CareCredit® Healthcare CreditCard
Care Credit allows you to begin treatment today and pay over time
Care Credit is available for any treatment amount
Care Credit can be used repeatedly - for your entire family - without having to reapply¹
Deposit & Billing: For extensive treatments or hospitalized care, a deposit may be required. Treatments requiring comprehensive care of $200.00,
or more will require a 50% deposit to begin your pet's treatment.
Additional Policy Information:
Macon County Veterinary Hospital charges 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 carrier.
There will be No Refunds for products, services or treatments rendered.
If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your pet.

Signature*

Upcoming Appointment Date/Time * **Please schedule and appointment prior to filling out this form*

Make sure to downloaded our app. Download it by scanning the QR code in App Store/Google Play.

*Create an account using the same email that we have on file for you. Please allow time for your information to be entered into our system. Your pet's will sync automatically (at a minimum of 24 hours) after all information is entered into our system by one of our team members. If you pets are not syncing automatically please contact us to verify email address on file.