Admissions Form
Fields marked with an * are required.
Client Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / 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 Vet
Drive by
Friend
Yellow Pages
Yelp
Social Media
Google
Other
Estimated Time of Arrival
*
Hour Minutes
AM
PM
AM/PM Option
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Patient (Pet) Information
Pet's Name
*
Sex
*
Male
Female
Spayed/Neutered?
*
Yes
No
Pet's Age
*
Breed
Color
*
Species
*
Canine (dog)
Feline (cat)
Other
Presenting Complaint
*
Patient Medical Information
Primary Care Veterinarian
*
Up to date on vaccines?
*
Yes
No
Heartworm / Flea / Tick prevention
Current Medication(s) & Duration
Have you visited Animal Emergency Hospital DeLand with this pet or any pet in the past?
Yes
No
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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
*
Cash
Check
CareCredit
ScratchPay
MasterCard
Visa
Discover
Photo Consent: AEHD may use images of my pet for marketing purposes
*
Yes
No
Signature for Authorization
Clear
Submit
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