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:

How would you like to pay your deposit?

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?

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Pet's Name

Species:

Pet Age

Pet Breed

Pet Color

Pet Gender

Is your pet spayed / neutered?

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)?

Please provide more information:

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

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?

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:

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

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

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.

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)

Please verify that you are human

IHS Veterinary Medical Center Appointment Request