AEHD Admissions Form

Admissions Form

Fields marked with an * are required.
Owner's Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Email*
example@example.com
How did you hear about us?

Primary Care VetDrive byFriendYellow PagesYelpSocial MediaGoogleOther
Estimated Time of Arrival*

MonthDayYear
Date
Hour MinutesAM/PM Option
Estimated Time of Arrival

Hour Minutes

AM/PM Option

Payment Acknowledgement
I understand that I am responsible for the initial examination and emergency fee regardless if treatment and diagnostics are performed. I understand that after the veterinarian on staff performs the initial exam, I will be presented with an estimate for diagnostics and treatment. I agree that should my account become delinquent, I will be responsible for all collection costs, including but not limited to the outstanding balance, attorney fees, court costs, collection agency fees, and interest at the rate of 18% per annum (1.5% per month).*

I agree
Please indicate your method of payment*

CashCareCreditScratchPayMasterCard*Visa*Discover*
*Please be aware that we do NOT accept American Express.

*If paying with a card, the person whose name appears on the credit card must be physically present.
Photo Consent: AEHD may use images of my pet for marketing purposes*

YesNo
Signature for Authorization

Clear
Should be Empty:

Admissions Form