Referral Form for Capital Home Veterinary Care Clients

Referring Dr.

Reason For Appointment

Radiographs Dental Procedure Surgical Procedure

Client Information

Primary Client Name

Secondary Client Name

Current Address

City

State / Province

Postal / Zip Code

Email Address

Cell Phone

Secondary Number

Consent to Email or Text Usage for Appointment Reminders and Other Healthcare Communications:

Call Text Email

Clients in our practice may be contacted via email and/or text messaging to remind you of an appointment(s), to provide treatment plans, 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 number forwarded or transferred to that number or emails to receive communication as stated above. 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 and general 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

Pet Information

Pet Name

Breed

Color

Age

Any medical history or allergies we need to be aware of?

If blood work has not been completed within 6 weeks of an anesthetic procedure, then it can be completed at Woodlake Animal Hospital at an additional cost. This is required for any anesthetic procedure.

Any cats with a heart murmur or at risk of heart disease will have a Cardiopet ProBNP completed at Woodlake Animal hospital prior to the anesthetic event.

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.

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.

Hospital Disclosure of Hours

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-5pm

Closed on Saturday and Sundays

Patients 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 of monitoring, they must be transferred to a 24-hour veterinary facility by their owner.

I understand that continuous medical care is not provided by medical staff in the hours outside of those listed above.

Signature acknowledging and accepting hospital policies:

Referral form for Capital Home Veterinary Care clients scheduling an appointment at Woodlake Animal Hospital