CAHWC New Client Enrollment Form

PHOTO RELEASE: During your pet(s) time with us, we may obtain video or photos for documentation in the medical record or training purposes.

Additionally, we may wish to obtain fun pictures of your pet(s), you and your pet(s), and/or your pet(s) and our team, for Facebook, Instagram, Twitter, TikTok, www.cardiffanimalhospital.com, and any other marketing and/or other social media outlets we may use.

Do we have your permission to post video or pictures of your pet? *

Yes No

I agree to release the Cardiff Animal Hospital & Wellness Center from all claims for libel, slander, invasion of privacy, infringement and copyright or right of publicity or any other claim and confirm that you are over the age of 18 years old. (Initial below) *

Type your initials here

PATIENT REMINDERS: The Cardiff Animal Hospital & Wellness Center uses email, text, and our own in-hospital application for communicating with clients regarding our patients for health care needs. The Cardiff Animal Hospital & Wellness Center no longer provides reminders for appointments or services due via standard mail. If you choose to not be contacted by email or text we cannot guarantee timely reminders regarding your pet(s) health.

Do we have your permission to contact you via email or text for reminders concerning your pet's health care needs? *

Yes No

If choosing to not provide permission to contact you digitally, please initial below indicating that you understand the above and release The Cardiff Animal Hospital & Wellness Center from any liability surrounding notification (timely or otherwise) regarding your pet(s) health care needs. *

Type your initials here

VETERINARY - CLIENT/PATIENT RELATIONSHIP (VCPR): In accordance with the principals of veterinary medical ethics as directed by the American Veterinary Medical Association (AVMA), the VCPR is the basis for interaction among veterinarians, and their clients and patients. The VCPR exists when the veterinarian assumes responsibility for making clinical judgement(s) regarding the health of the patient and has sufficient knowledge of the patient to initiate treatment. In accordance with the California Veterinary Medical Board (CVMB), to maintain a VCPR, a thorough examination of the patient must be performed within one year of any treatments or medications administered or prescribed for a given condition.

Initial here to indicate you have read and understand the VCPR *

Type your initials here

RETURN OF PRESCRIPTION MEDICATIONS AND PRODUCTS: In accordance with the FDA Compliance Policy Guideline 7132.09 and the Health and Safety Code Section 11400, we can not accept the return of any prescription medications or products.

Initial here to indicate you have read and understand that prescription medications and products may not be returned *

Type your initials here

PAYMENT DUE AT THE TIME OF SERVICE AND FORMS OF PAYMENT: Payment for all services is due at the time services are rendered. At your request, we will gladly discuss the cost of all services and/or prepare a written estimate of costs for all recommended treatment(s) or services.

ACCEPTED FORMS OF PAYMENT: We accept payment in the form of cash, Visa, Mastercard, and Discover. We DO NOT accept American Express or checks.

THIRD PARTY FINANCING: In addition, we also accept third party financing options for our clients via Care Credit and Scratchpay.

SPECIAL CARE CREDIT CONSIDERATIONS: (1) We only accept the 6-month term with Care Credit. (2) Care Credit requires that payment only be made for services as they are rendered, we therefore cannot charge services to your account in advance. (3) The use of Care Credit requires that the card and card holder be present at the time of payment, and that two forms of identification are verified. We appreciate your understanding of our desire to protect your account/identity.

As financing options are available, we do not offer any payment plans for our services.

Please initial below to indicate that you have read and understand that payment is due in full at the time of services, as well as the accepted forms of payment *

Type your initials here

TREATMENT CONSENT & ACKNOWLEDGEMENT OF ALL TERMS

By signing this document, I declare that I am the lawful owner of all listed pets and all of the information provided is true and correct to the best of my knowledge.
I hereby authorize the veterinarian(s) of the Cardiff Animal Hospital & Wellness Center to examine, prescribe for, and treat my pet(s) to the best of their abilities.
I assume responsibility for all charges incurred in the treatment and care of my pet(s).
I acknowledge that medical information will not be released to anyone not indicated on this form without my express verbal and/or written permission with the exception of another veterinary facility.

Your Signature Below *

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Date *

Date

Cardiff Animal Hospital & Wellness Center

CLIENT INFORMATION

PET INFORMATION

PET INFORMATION (#2)

PET INFORMATION (#3)

POLICIES & PROCEDURES