New Client Form - Woodlake Animal Hospital

Owner's Full Name

Spouse’s Name

Address

City

State

ZIP

Cell Phone

Home Phone

Work Phone

Preferred Form(s) of Contact

Phone Email Text

Employer

Spouse’s Phone

Alternate Contact (In case of emergency)

How did you hear about us?

Whom may we thank for referring you?

Pet’s Name

Species

If other, Please specify Species

Age/Birthdate

Sex

Color

Weight (lbs)

Breed

Known Allergies

Have you scheduled an exam?

Yes No

Where was your pet previously seen?

City/State

Phone Number

We routinely prepare a written estimate. All professional fees are due at the time services are rendered. In cases of extensive medical or surgical procedures where full payment may be difficult at discharge we accept MasterCard, Visa, Discover or American Express. We also accept CareCredit and can extend 0% financing for 6 months with invoices over $200 through CareCredit. We do not offer any billing terms or accept checks. 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 and that a deposit may be required for treatment. I also understand I will be responsible for additional collection fees if an unpaid account is sent to a collection agency. I understand that no continuous medical staff care will be given at any hours outside our normal open business hours which are: Monday through Friday 8am to 5pm.

I understand and agree

Consent to Email or Text Usage for Appointment Reminders and Other Healthcare Communications: Clients in our practice may be contacted via email and/or text messaging to remind you of an appointment(s), to obtain feedback on your experience with our healthcare team, and to provide general health reminders/information.

I understand and agree

If at any time I provide an email or text address at which I may be contacted, I consent to receiving appointment reminders and other healthcare communications/information at that email or text address from the Practice.

I consent to receive text messages from the practice at my cell phone and any numberforwarded or transferred to that number or emails to receive communication as statedabove. I understand that this request to receive emails and text messages will apply to all future appointment reminders/feedback/health information unless I request a change. The cell phone number that I authorize to receive text messages for appointment reminders, feedback, and general health reminders/information is

The email that I authorize to receive email messages for appointment reminders andgeneral health reminders/feedback/information is

The practice does not charge for this service, but standard text messaging rates may apply as provided in your wireless plan (contact your carrier for pricing, plans, and details).

I understand and agree

Payment: Payment for office visits, procedures, and products is due in full, at the time services are rendered. Our staff is available to discuss our payment policy and your account at the time of the visit. As we do not offer bill options or payment plans. We accept Cash, Care Credit, and all major Credit/Debit Cards. We do not accept Checks. Appointments: To meet the needs of all our clients, we see our patients by appointment only. We understand that from time to time, appointments may need to be changed or cancelled. We request that appointments be cancelled as soon as possible prior to the appointment time. Appointments that are not kept, and are not cancelled, significantly add to the cost of medical care. Therefore, if you do not cancel an appointment, we must charge you for the visit. The charge will be based on the appointment reason, and the time that was reserved for this appointment. Statements: Statements are mailed out on all outstanding balances each month and are due in full upon receipt. We reserve the right to impose a finance charge on all past due accounts. A billing fee of $5.00 will be added to the account balance upon the first statement being sent. For each additional monthly statement that is mailed out, a 1 ½ % finance charge will be imposed on all accounts. If my account becomes past due, and I have not contacted the office with a payment arrangement, the account may be forwarded to an attorney for collection. I will then become responsible for reasonable attorney’s fees and court costs involved in the collection of past due accounts. Should this occur, I agree to pay all attorney or collection agency fees (not to exceed 40%), and all court costs incurred by Woodlake Animal Hospital. I, the undersigned, agree to accept full financial responsibility for service rendered by Woodlake Animal Hospital. I agree to abide by the conditions outlined in this payment policy.

I understand and agree

Date

I am aware that Woodlake Animal Hospital does not provide 24-hour medical/patient care and that the staffing hours are as follows: Monday through Friday: 8am - 5 pm closed Saturday and Sunday: Closed Patient that are dropped off for treatment/surgeries are required to be picked up prior to the close of day. If a patient requires overnight treatment or monitoring, they will need to be transferred to a 24-hour veterinary facility by the pet owner- we do not provide this service. When the medical staff are not on site, we refer our clients to VVC Cary Street: 3312 W Cary St, Richmond, VA 23221 (804) 353-9000 (Staffed 24 hours) I understand that continuous medical care is not provided by medical staff in the hours outside of those listed above.

I understand and agree

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