Client Registration Form

If you have more than 5 pets, we will collect further information when we receive your records. 

I hereby authorize Alexandria Animal Hospital and their veterinarians to examine, prescribe for, or treat, the described pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release.

 

I hereby grant Alexandria Animal Hospital and their veterinarians the right to retain possession of the described pet(s) until such time as payment is made in full on the account or satisfactory payment arrangements are made. In addition, I acknowledge that I shall be liable for any and all expense associated with boarding the pet(s) until payment is made.

Thank you for choosing Alexandria Animal Hospital. Our primary mission is to deliver the best and most comprehensive veterinary care available for your pet. An important part of this mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options. Alexandria Animal Hospital requires payment in full at the end of your pet's examination and/or at the time of discharge.

 

In consideration of the services to be provided to the client/patient, I/we hereby guarantee payment in full of the client's account in accordance with the financial arragements made at the time of service/purchase or, if no such arrangements are made, in event of default in payment, reasonable collection agency fees equal to thirty (30%) percent of the delinquent balance and reasonable attorney fees, shall be added to the amount due on the account, plus any applicable court costs.

 

You expressly consent and agree to Alexandria Animal Hospital and their affiliates, agents and service providers may use written, electronic or verbal means to contact you. This includes, but is not limited to conact by manual methods, prerecorded or artificial voice messages, text messages, emails and/or automatic telephone number you provide, now or in the future, including a number for a cellular phone or other wireless decvice, regardless of whether you incur charges as a result.

 

Payment Options:

• Cash
• Check
• All major credit cards (Visa, Mastercard, American Express, Discover Card)
• CareCredit Healthcare CreditCard
• Scratchpay
• Trupanion Vet Direct Pay
  
  

For some treatments such as hospitalized patients or surgery, a deposit may be required. We will require half of the low end of estimate provided as a deposit to begin your pet's treatment.

 

Additional Policy Information:

Alexandria Animal Hospital charges $25 for returned checks.

We work with a variety of different pet health companies. We encourage all clients considering learning about the many different options available. For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier.

If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your pet.

By signing below, you agree to the foregoing terms of payment.

I hereby grant permission to Alexandria Animal Hospital (Alexandria, Indiana) to use my and my pet's photograph on it's internet sites and/or in other official promotional printed or internet publications without further consideration/permission.

 

I acknowledge Alexandria Animal Hospital's right to crop or treat the photograph at it's discretion. I also acknowledge that the hospital staff may choose not to use my photo at this time, but may do so at it's own discretion at a later date.

 

I also understand that once my image is posted on an internet site, the image can be downloaded by any computer user. I understand that Alexandria Animal Hospital and its staff cannot control to unauthorized use by persons other than the hospital once the image is published on the world wide web. Any claim I have conerning the unauthorized publication of my image must be pursued by me against the unauthorized user. Alexandria Animal Hospital disclaims any responsibility for any unauthorized use of my published image.

 

CONSENT INCLUDED BUT NOT LIMITED TO ALEXANDRIA ANIMAL HOSPITAL WEBSITE, FACEBOOK, INSTAGRAM, GOOGLE, PRINTED MATERIAL, AND/OR PROMOTIONAL EMAIL/TEST.