Levittown Animal Hospital New Client Registration Form

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Secondary Phone Number

Please enter a valid phone number.

May we contact you at work?*

YesNo

If yes, what is your work number and extension?*

E-mail*

example@example.com

Who else is authorized to make decisions about your pet’s healthcare?

Their Phone #

Their Cell/Work Phone #

How did you hear about us?*

If client, employee, or other doctor/hospital, who can we thank?*

Pet's Name*

Date/Year Born*

Sex*

MaleFemale

Has your pet been spayed/neutered?*

YesNo

Species*

DogCatOther

Breed*

Colors & Identifying Markings*

Does your pet have a microchip Identification?*

YesNo

In the last 12 months, has your pet had a complete physical examination?*

YesNo

In the last 12 months, has your pet had regular vaccinations?*

YesNo

Do you have health insurance for your pet? Levittown Animal Hospital advocates the use of Pet health insurance. We can assist you in preparing, filing and sending claim forms in order to expedite your reimbursement.*

YesNo

Please upload a photo of your pet for our records

FINANCIAL POLICY: Payment is due in full at the time that services are performed. If admitted into the hospital, we cannot begin the care of your pet until you have confirmed your desire to do so by 1) signing the client consent & estimate form, and 2) leaving an initial deposit of 50% of the upper end of the estimate. This is the only way that we can know for certain that you want us to proceed with the care of your pet.

We accept cash, Visa, Mastercard, American Express, Discover, and CareCredit payments. We can accept personal checks (NOT business or money market checks) if and only if you can provide a driver's license, non-driver identification card, or military identification with a SS number. When paying by check, you can authorize us to use the account information from your signed check to make an electronic fund transfer (EFT) from your account for the same amount as the check. The EFT from your account will usually occur within 24 hours, which is faster than a check is normally processed. Therefore, make sure there are sufficient funds available in your checking account at the time of the payment. All checks are subject to check guarantee services.

There is a $50 fee for checks that are drawn against an account with insufficient funds. We neither extend credit, nor bills for services. All open invoices are sent to collections after 45 days unless prior arrangements are made. Your initials in the following space will indicate that you have read and accepted our financial policy

Signature*

Today's Date*

Date

LAH - New Client Registration Form

New Client Registration

Pet Information

Financial Policy