IHS Veterinary Hospital Request EZ Vet

A DEPOSIT IS NOW REQUIRED TO BOOK AN APPOINTMENT. All appointments require a deposit to complete booking. This deposit is non-refundable, however, you may reschedule your appointment within 48 hours if you are unable to make your originally scheduled appointment. Missed appointments will result in the deposit being donated to our nonprofit.

After you submit this form, you will receive a link via email or text to pay your deposit. Once the deposit is accepted, you will be contacted to set up an appointment.

Client Name*

First NameLast Name

Client Email*

example@example.com

Client Phone*

Area CodePhone Number

Preferred Contact Method:*

CallTextEmail

How would you like to pay your deposit?*

Credit or Debit CardCare CreditCash in Person

Deposit Payment

Credit or Debit Card

$70.00 Quantity

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

CareCredit must be processed directly by staff, either in person or by phone. If you select this option, please expect contact to complete your transaction.

How would you like to be contacted for the Care Credit deposit?*

I will come inPlease call mePlease text me

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Pet's Name*

Species:*

DogCat

Pet Age*

Pet Breed*

Pet Color*

Pet Gender

MaleFemale

Is your pet spayed / neutered?*

YesNoI don't know

Pet's Veterinary Need (Dental, Mass Removal, Type of Orthopedic Surgery, etc)*

Do you currently have any medical concerns? If so, please explain:*

Does your pet have records at another vet clinic that would be useful to a veterinarian (lab work x-rays, vaccines)?*

YesNoNot Applicable

Please provide more information: *

Do you give us consent to contact your previous vet to request veterinary records?

Yes. Please note: we will attempt to contact your previous veterinarian for records as requested, but we advise you to please acquire a copy of the record yourself or call and request them to be sent to us as some clinics require releases. Records can be sent to: vetclinic@idahohumanesociety.orgNo

Please list the veterinary office your pet visited to start a transfer of medical records. If outside of the Treasure Valley, please include phone number*

Are you transferring care to IHS because you cannot afford veterinary care elsewhere?*

YesNoUnsure

Does anyone in your household receive any form of public assistance from a state or federal program? Please check any of the following that apply:*

SNAP (also known as food stamps)Housing (Section 8, Public Housing, etc)Child Care Assistance (ICCP: Idaho Child Care Program)SSDI: Social Security Insurance DisabilityMedicaidNone of these

Are you, or any adult member of your household (please check any of the following that apply):*

UnemployedRetiredReceive Social SecurityNone of these

IHS may be able to provide financial assistance. Please help us understand if you may qualify for any of the following:

10% Senior Discount (Aged 60+)I am experiencing extenuating circumstances and I would like to apply for a grant (most spays/neuters will not qualify for a grant).Payment Plans (you must first be denied via CareCredit or ScratchPay to qualify) and you must agree to spay/neuter if pet is not already fixed.N/A I will pay in full at checkout

How many dogs and cats are in your household?*

How many of those pets are spayed/neutered?*

How many individuals 18+ years of age are living in the same household (please exlude roommates)?*

How many persons under the age of 18 are you responsible for?*

What is your total net (take-home) household income? (Jan-Dec in a calendar year)*

To the best of your knowledge, I certify that the information provided is true. *

Any additional information you'd like to share?

0/500

Please provide your financial information below to complete your deposit. If you are unable to pay now, a staff member will reach out to you make arrangements over the phone prior to scheduling service for you.

DebitCreditCare Credit

In order for us to identify the population we are serving, we kindly request your household income and family size.

Household Net Income (take-home January thru December in a calendar year).*

Current Household Members (please exclude roommates)*

1-2 People3 People4 People5+ People

Please verify that you are human

IHS Veterinary Medical Center Appointment Request