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New Client & Financial Policy Form

Owner's Name(Required)

First

Last

Spouse/Other

Address

Street Address

Address Line 2

City

State

ZIP Code

Phone

How did you hear about us?

Yellow Pages

Sign

Recommendation

Other

Do you give us permission to post your pet on social media?(Required)

Yes

Have you downloaded PetDesk, our client-facing app?(Required)

Yes

if recommended, by whom?

Pet #1

First Pet's Name

Date of Birth

MM slash DD slash YYYY

Pet Photo

Max. file size: 50 MB.

Type of Animal

Dog

Cat

Other

Sex

Male

Female

Is he/she spayed or neutered?

Yes

Breed

Color

Are Vaccinations current?

Yes

Does your pet have a microchip?

Yes

Is your Pet's chip registered?

Yes

Current Medications, if any:

Describe your pet's diet

Reason for visit

Pet #2

Second Pet's Name

Date of Birth

MM slash DD slash YYYY

Pet Photo

Max. file size: 50 MB.

Type of Animal

Dog

Cat

Other

Sex

Male

Female

Is he/she spayed or neutered?

Yes

Breed

Color

Are Vaccinations current?

Yes

Does your pet have a microchip?

Yes

Is your Pet's chip registered?

Yes

Current Medications, if any:

Describe your pet's diet

Reason for visit

Consent(Required)

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet(s). By signing this form, I agree I am 18 years or older and I assume full 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 maybe required for surgical treatment.

Social Media & Website Consent

Consent

I authorize the staff at Pine Point Animal Hospital to use photos of my pet on social media and their website

Financial Policy

Thank you for choosing Pine Point Animal Hospital. 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. Pine Point Animal Hospital requires payment in full at the end of you pet’s examination and/or at the time of discharge.

Payment Options

Cash, Check, Visa®, Mastercard® or Discover Card®

Convenient Monthly Payment Plans from CareCredit®

Deposit and Billing

For some treatments or hospitalized care, a deposit may be required. Healthcare plans requiring comprehensive care of or more, will require a deposit to begin your pet’s treatment. We may offer in-house payment options on a case-by-case basis. We charge 1.5% interest on all outstanding account balances older than 30 days. If you have an account 120 days past due, Pine Point Animal Hospital may relinquish your balance owed to a collection agency.

Additional Policy Information

Pine Point Animal Hospital charges $25.00 for returned 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.

Client/Owner Signature(Required)

Date(Required)

MM slash DD slash YYYY

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