New Client Registration Form

New Client Registration Form
PRIMARY CONTACT Full Name *

Prefix First Name Last Name Suffix
PRIMARY CONTACT Phone Number *
This phone number is a *

Mobile phone Landline
PRIMARY CONTACT E-mail

Confirmation Email example@example.com
SECONDARY CONTACT Full Name - Optional

Prefix First Name Last Name Suffix
SECONDARY CONTACT Phone Number
Please enter a valid phone number.
This phone number is a

Mobile phone Landline
SECONDARY CONTACT Email

Confirmation Email example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How did you hear about us? *
Referral or Other *
Please let us know who we may thank for the referral!
Financial Policy

All services and products must be paid for at the time of service.
Our fee structure at Mt. Carmel Animal Hospital is based on the financial realities of providing superior care for your pet(s). We offer state-of-the-art facilities and equipment, and well-trained and experienced clinical staff, which enable us to provide superior client and patient care. We encourage you to discuss charges and fees for services before they are rendered. We are always happy to provide a written treatment plan with an estimate of fees before providing any service.

MCAH accepts cash, personal checks, debit, and credit cards (Visa, Mastercard, Discover, American Express). While in-house financing and payment plans are not available, we do accept two forms of financing: Scratchpay and Care Credit.

Default on payments due, including checks returned for insufficient funds, are subject to legal action as allowed by law. Finance charges accrue 1.5% monthly (18% annual rate). Collection fees, bookkeeping fees, and billing charges may also be incurred.
I have read the Financial Policy and understand that payment is due at the time of service. *

Yes
We love to take pictures of our patients and share them! *

I grant permission for photo(s) of my pet(s) to be used on MCAH website, social media, and advertising. I do not agree to photo release.
Signature *

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New Client Registration Form

Financial Policy