New Patients Center

Phone Numbers (Please check primary number)

Home Address:

Mailing/2nd Address:

Employer:

Spouse/Co-Owner:

Email Address:

How did you hear about us?:

· WE DO REQUIRE A COPY OF A VALID PHOTO ID ·

We will gladly prepare a written estimate for services, if you desire, please ask the technician or doctor. PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. We accept cash, Master Card, Visa, Debit, American Express, Discover and Care Credit. WE DO NOT ACCEPT CHECKS, WE APOLOGIZE FOR ANY INCONVENIENCE.

In the event any balance due is not paid as agreed, the undersigned jointly and severally agree to pay all costs included in said unpaid balance, including a reasonable collection and/or attorney’s fees. A monthly “service charge” of 15% will be added to all accounts that exceed 30 days. In the event of a credit card refund a 12% service charge will be assessed prior to issuing the refund.

Federal law prohibits the dispensing of certain medications without examination or prescription. Your understanding is appreciated. Some prescription drugs may be available at a pharmacy. After hour treatment of patients is at the discretion of the veterinarian. I authorize the veterinarian at Vistancia Animal Hospital to diagnose, prescribe, perform therapeutic procedures, and/or surgery on my pet(s). No warranty or guarantee has been made as to result or cure.

I have read and fully agree to the above statements:

I DO / DO NOT Authorize photography of my pet(s) for clinic media and client update purposes.