PATIENT / CLIENT INFORMATION
Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted with you and your pet, please complete the following:
(Please Print)
Name: ______________________________________________________________________ Last First Middle Initial Address: ______________________________________________________________________ P.O. Box Must Include Physical Address _____________________________________________________________________ City State Zip Code Owner’s Driver’s License # ________________________________________ Home Phone: __________________________________________________ Work Phone: __________________________________________________ Cell Phone: ____________________________________________________ Employer: _____________________________________________________ E-mail Address: ________________________________________________ SPOUSE / SIGNIFICANT OTHER |
Name: _____________________________________________________________________ Last First Middle Initial Address: _____________________________________________________________________ P.O. Box Must Include Physical Address ___________________________________________________________________ City State Zip Code Driver’s License # _________________________________________________ Home Phone: ____________________________________________________ Work Phone: ____________________________________________________ Cell Phone: _____________________________________________________ Employer: _______________________________________________________ E-mail Address: ___________________________________________________ |
INFORMATION | PET #1 | PET #2 | PET #3 |
Pet’s Name | | | |
Species (Canine/Feline) | | | |
Breed (Poodle, etc) | | | |
Color | | | |
Age/Date of Birth (if known) | | | |
Sex | Male Female | Male Female | Male Female |
Spayed (F) Neutered (M) | Yes No | Yes No | Yes No |
Vaccination History (Dates) | | | |
Rabies (Canine/Feline) | | | |
Canine Distemper | | | |
Bordetella (Canine) | | | |
Lyme (Canine) | | | |
Heartworm Test (Dog/Cat) | | | |
Combo Test (Feline) | | | |
Feline Distemper | | | |
Feline Leukemia | | | |
Other | | | |
Signature: ___________________________________________ Date: ____________________
PLEASE READ AND SIGN OUR FINANCIAL POLICY ON REVERSE SIDE
The mission of Ranson Animal Hospital is to fulfill the needs of our clients by providing quality pet health care services through a responsive, professional staff with the emphasis on individual attention and commitment to our clients, their pets, and our community. We will never be the reason any pet does not have the opportunity for the best care veterinary medicine has to offer.
Our hospital does not receive financial support from charitable organizations or government agencies. Therefore, prompt payment assures maintenance of a well-equipped, properly stocked facility, as well as a professional medical staff to insure the highest level of quality care which we strive to provide. Due to the fact that prompt payment must be insured in order for us to provide this level of care, the following financial policies are required:
- Payment in full is required for all routine services at the time of service. For your convenience, we accept cash, personal check, credit/debit cards (Visa, Master Card, and Discover) for the amount of the invoice only.
- A minimum of 50% of the estimate is required as a deposit at the time of admission for all major surgical procedures and hospitalization. However, elective surgeries do not qualify and must be paid in full at the time the pet is released from the hospital.
- Emergency cases require a minimum of 50% of the written estimate at the time of admission of the pet the hospital.
- Our financial policy strictly prohibits the establishment of any charge accounts at this time.
- Care Credit is also available – ask a staff member for details.
We thank you in advance for your time and consideration of this policy
Signature: _________________________________________ Date: ______________________
