Add a Pet to an Account Form

Add a Pet to an Account Form

Please complete the information on this form to add a pet to an existing account at Cottonwood Animal Clinic. Please allow 2-5 business days for us to process your submission.
Primary Owner Information

Please bring a State issued picture ID such as a driver's license to your first appointment to complete the set up of your account.
Full Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type
Co-Owner Information (if applicable)
Co-Owner Full Name

First NameLast Name
Co-Owner Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type
Pet Information

This form allows up to two pets to be added to an account. If you need to add more than two pets, please submit the form again.
First Pet Name
First Pet Species
First Pet Breed
First Pet Color
First Pet Date of Birth (or estimate)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
First Pet Gender
Microchip number
First Pet Previous Medical or Vaccine Records

Upload previous medical records or vaccine records. Multiple files are allowed.
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Second Pet Name
Second Pet Species
Second Pet Breed
Second Pet Color
Second Pet Date of Birth (or estimate)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Second Pet Gender
Microchip number
Second Pet Previous Medical or Vaccine Records

Upload previous medical records or vaccine records. Multiple files are allowed.
Cancelof
Financial Responsibility Agreement
I, {q3_fullname1}, acknowledge and agree that I am financially responsible for all veterinary services, products, medications, diagnostics, hospitalization, and other charges provided to any animals under this account. Payment is due in full at the time services are rendered or products are provided, unless a payment arrangement has been approved in writing by Cottonwood Animal Clinic prior to services being provided.

I understand that any estimate provided by Cottonwood Animal Clinic is an estimate only and that the final amount due may vary based on the services, medications, diagnostics, treatment, or other care actually provided. I authorize Cottonwood Animal Clinic to provide veterinary care that I request or authorize and agree to pay all resulting charges.

If I intend to seek reimbursement from a third party, including but not limited to pet insurance, I understand that I remain solely responsible for payment of my account. Insurance reimbursement or disputes with an insurance company do not delay, reduce, or otherwise affect my obligation to Cottonwood Animal Clinic.

If I am unable to pay the balance when it is due, I agree to notify the clinic before services are provided and request a payment arrangement. Payment arrangements are not guaranteed and are valid only when specifically approved by Cottonwood Animal Clinic in writing.

I understand that unpaid balances may be subject to a service charge of 3% per month (or a minimum of $3.50 per month) beginning 30 days after the balance becomes due, as permitted by applicable law. I further understand that unpaid balances may be subject to collection efforts and any lawful fees or costs associated with collection. I agree to be responsible for all such service charges, fees, and costs.

By signing below, I acknowledge that I have read, understand, and agree to the financial responsibility terms above.
Signature of Financially Responsible Party
Should be Empty:

Add a Pet to an Account Form

Primary Owner Information

Co-Owner Information (if applicable)

Pet Information

Financial Responsibility Agreement