WELCOME TO SOUTHER HILLS ANIMAL HOSPITAL
Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following:
Name of Primary Client or Responsible Party:
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First Name
Last Name
Primary Phone #
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Please enter a valid phone number.
Primary Phone is a Cell#?
Yes!
I don't text.
OK to text this #?
Text this # instead:
Primary Contact Email
example@example.com
Name of Spouse or Co-Owner
First Name
Last Name
Spouse / Co-Owner Phone #
Please enter a valid phone number.
Mailing Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
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First Name
Last Name
Emergency Contact Phone #
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Please enter a valid phone number.
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Patient Information
Pet Name (#1)
*
Configurable list
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Take Photo
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Terms, Conditions & Agreement
I hereby authorize the veterinarian to examine, prescribe for and/or to treat my animals.
I understand that all fees are due at the time services are rendered.
I understand I will be required additional personal information at time of Client Registration (including Date of Birth, Driver's License and Social Security Number). This information is kept completely secure and is necessary to prescribe medications and required for payment.
I agree to reimburse Southern Hills Animal Hospital the fees of any collection agency, which may be based on a percentage at a maximum of 30% of the debit, all costs and expenses, including attorney's fees, which incur in such collection efforts.
I understand and agree to the hospital's "NO-CALL/NO-SHOW" POLICIES
:
Southern Hills Animal Hospital frequently books Scheduled Appointments 2 weeks in advance; Surgical Procedures book out at least 2 months in advance. When clients "No-Call, No-Show" for appointments and procedures, other sick pets are not able to be seen or treated! Scheduled Appointments should be rescheduled no less than 24 hours, or 1 full Business Day; Scheduled Procedures require 3 full Business Days advance notice to reschedule. "No-Call, No-Shows" can result in a "No-Show" Appointment Fee or a Surgical Scheduling Fee added to that client's account.
I agree to all terms and conditions detailed in this form.
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Yes
Signature
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