|E-Mail Address : |
|Date of Birth (needed to dispense controlled drugs): (required)|
|How did you hear about us? If recommended, whom may we thank?|
|Pet's Name (required)|
|Age: Years, Months|
|Type of Pet (required) : |
|Are your pet's vaccines current?|
|Do you have your pet's medical records?|
|Medical records at another veterinary Practice?|
|Name of Former Veterinary Practice|
|May we request a transfer of records?|
|Would you like us to call you for your appointment?|
|Reasons or conditions that prompted your visit?|
|Is your pet currently on any medications?|
|Please list any additional pets here|
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Clyde Park Veterinary Clinic and that CHARGES ARE DUE AND PAYABLE AT THE TIME OF SERVICE.
We will gladly prepare a written estimate if you desire. In instances of extensive medical or surgical procedures where full payment may be difficult at discharge, we accept Care Credit, Visa, MasterCard, and Discover, or can, as a last resort, establish a payment agreement if approved prior to treatment. There will be a $35 service charge for any returned check. Any balance that I leave unpaid will be forwarded to Clyde Park Veterinary Clinic's collection agent, and will incur a collection fee for which I am liable, in addition to monthly finance charges. I agree to reimburse Clyde Park Veterinary Clinic the fees of any collection agency, which may be based on a percentage at a maximum of 30% of the debt, and all costs, and expenses, including reasonable attorneys' fees, they incur in such collection efforts. A $5 billing fee will be applied to all outstanding account balances older than 30 days.
To prevent the spread of infectious diseases, and for the protection of our other patients, all hospitalized pets must be current on vaccines and free from internal and external parasites. If your pet is found to have fleas while here for grooming, your pet will be treated immediately with CapStar and you will be charged a small fee. By indicating that I agree below, I authorize this minimum level of preventative care and the appropriate charges will be assessed in the discharge invoice.
Must be 18 years or older to submit this form.
|I have read this statement and - (required)|