gardneranimalhospitalpc.com - Patient-Client Information

Patient - Client Information
Thank you for giving us the opportunity to care for your pet. Please help us better meet your needs by taking a few moments to fill out both sides of this information sheet.
Owner’s Name:
Spouse/Other:
Owner DOB:
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Please enter a valid phone number.
Cell Phone:
Please enter a valid phone number.
Email:
example@example.com
Employer’s Name & Address:
Work #:
Please enter a valid phone number.
In case of EMERGENCY call:
Phone Number:
Please enter a valid phone number.
Responsible Party (if there is someone other than yourself who is financially responsible for this bill):
Responsible Party Phone:
Please enter a valid phone number.
Email
example@example.com
Employer’s Name & Address:
Work #:
Please enter a valid phone number.
Name & Location of Previous/Current Veterinarian:
How did you hear about us?

Individual; Who may we thank?GoogleFacebookInstagramNewcomer’s GuideOther:
Individual : Whom may we thank?

Animal Medical History
Please complete information for all your pets to the best of your ability.

Records from previous veterinarian may be emailed to gah@eufaula.rr.com or faxed to (334) 687-4772.
Name & Location of Previous/Current Veterinarian:

	Pet # 01	Pet # 02
Pet’s Name
Species (Dog, Cat,)
Breed
Color / Markings
Age or DOB
Male / Female
Altered / Unaltered(Yes or No)
Flea/Tick Control Used
Heartworm Preventative Used

Vaccinations

DOGS:

	Pet # 01 (Date)	Pet # 02 (Date)
DA2PP (Distemper/Parvo)
Bordetella (Kennel Cough)
Rabies (1 years or 3 years)
Lyme
Corona (Dogs) This is not Covid-19
Other Vaccines (Please specify)

CATS:

	Pet # 01 (Date)	Pet # 02 (Date)
FVRCP (Infectious Diseases)
FELV (Feline Leukemia)
Rabies (1 yr or 3 yr)
Other Vaccines (Please Specify)

I understand that in order to help prevent the spread of infectious diseases, ALL hospitalized and boarding animals must be current on the following vaccinations: RABIES, BORDETELLA, INFLUENZA (Canine), PARVO, DISTEMPER (Both Canine & Feline). Due to state law and insurance requirements, all dogs and cats must be current on their Rabies vaccination. Vaccinations can be updated at the time of your appointment if they are not current. We will gladly prepare an estimate for expected services if you desire.I understand every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care and handling. I, the undersigned, do hereby authorize this hospital to receive, prescribe for, treat or perform surgery upon the pet(s) listed on the next page and additional pets I present. Furthermore, I agree to pay fees for services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated. I agree to pay for the reasonable costs of collection if collection efforts become necessary. I understand that a service fee of $30.00 will be assessed for each non-sufficient funds check and/or certified letter that must be sent. All accounts unpaid after 30 days receive a $5.00 billing charge each month and a late charge computed at a periodic rate of 1.80% per month, which is an annual percentage rate of 18.00% with a minimum monthly charge of $5.00. I understand that emergency veterinary service is provided after normal business hours as deemed necessary by the veterinarian on call, and that a deposit will be required for such service. If I neglect to pick up my pet within 5 days of the discharge date and do not notify the hospital within that time period, you may assume that the pet is abandoned and are hereby authorized to humanely dispose of the pet as you deem best and/or necessary.

Financial Policy
PROFESSIONAL FEES ARE DUE AT TIME SERVICES ARE RENDERED.

The following financial policies are mandatory for our hospital to perform the high level of care we strive to provide for your pet. All balances must be paid in full at the time of service. Gardner Animal Hospital accepts cash, local checks (with SSN, DL#, DOB, phone number and current address), major credit cards, Care Credit and Scratch Pay. Major surgeries, hospitalization and emergency services require a 50% deposit of the ESTIMATED charges expected. Emergency cases require a minimum $300 deposit at the time of admission for intensive care therapy to be initiated. At any time, Gardner Animal Hospital reserves the right to require a deposit prior to boarding or other services provided. Gardner Animal Hospital does not permit charge accounts.
I agree to the terms and policies set forth in the above financial policy.I understand that PROFESSIONAL FEES ARE DUE AT TIME SERVICES ARE RENDERED.I understand that Gardner Animal Hospital does not offer payment plans.
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Patient - Client Information

Animal Medical History

Financial Policy