Client Information Form

Owner's Name
First Name* Last Name*
Spouse/Co-Owner's Name
First Name Last Name
Owner's Contact Information
Address*
City* State* Zip*
Cell Phone* Home Phone
Email*


How were you referred to our hospital?*
Client ReferralVet ReferralInternetDrove ByOther:
Regular Veterinarian?*


Pet Information
Pet Name*
DOB* Species*
Gender* Breed*
Color* Weight


Agreement & Policies

To insure proper medical care for your pet(s), and for your convenience, Animal Medical and Surgical Center will enter your pets in our Computerized Recall System which will automatically mail you a reminder card at the appropriate time for all necessary vaccinations and exams. Please notify us of any address and/or phone changes.

FINANCIAL POLICY: Animal Medical and Surgical Center would like you to be aware that all fees are due when services are rendered. By signing below, I authorize Animal Medical & Surgical Center to process payment on my account using payment information provided by me. I understand that no guarantee can be made as to the results obtained from medical treatment. As legal owner or responsible agent of the above pet(s) I certify that I have read and agree to the above financial policy. I hereby assume financial responsibility for all services rendered.

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

Payment Options:
- Cash, Visa®, MasterCard®, American Express® or Discover Card®

CareCredit
- Convenient Monthly Payment Plans allow you to begin treatment today and pay over time (subject to credit approval)
- Available for any treatment amount
- Can be used repeatedly, for your entire family, without having to reapply

ScratchPay
Upon approval, your vet is paid and your pet gets the care they need. There are no hidden fees or retroactive interest charges – just simple, affordable options for pet owners in need.

Additional Policy Information:
Animal Medical and Surgical Center does not accept checks 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

Accept*

Media Release:
From time to time, we may take photographs of our patients while at our hospital. We use these pictures on social media, our website, and in advertising because we love what we do and want to share those experiences with our pet parents and our community! If your pet is here on an emergency basis, we would respectfully and tastefully use any potential photos/video for educational purposes for our clients, staff, and community. (example: snake bites, common illness, unique cases). Photos/videos are not taken of every patient, and only photos/videos of fully recovered emergency patients would be shared in any media outlets.

ApproveDecline

Signature of Owner Date*