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The doctors and staff of PetDocks thank you for the opportunity to provide veterinary care for your pet
family member. Please take a few moments to fill out this form as completely as possible.
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Physical Address (if different)
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Professional fees are due at the time services are rendered. If you wish to pay by check, credit card, bank or
debit card, please complete the following:
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Driver's License (state and number)
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How did you hear about PetDocks Veterinary Hospital?
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Is there someone we may thank for referring you?
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Saw our hospital
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Newspaper
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Website
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Radio
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Yellow Pages
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Other
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Although you are responsible for any charges accrued while your pet is here, is there anyone you give
permission to drop off or pick up your pet in your place?
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Name
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Contact Phone Number
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Pet #1
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Dog
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Cat
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Other
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Vaccinations last given by (clinic name)
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Date
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Current Medications
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Previous Surgeries
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Allergies
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Long-term Medical Problems
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Pet #2
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Dog
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Cat
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Other
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Vaccinations last given by (clinic name)
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Date
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Current Medications
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Previous Surgeries
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Allergies
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Long-term Medical Problems
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To help prevent the spread of infectious diseases,
ALL hospitalized and boarded animals must be current on all vaccinations.
DUE TO STATE LAW AND INSURANCE REQUIREMENTS,
ALL DOGS AND CATS MUST BE CURRENT ON RABIES VACCINATION.
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Name of Current/Previous Veterinarian
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Are you bringing verification of rabies status with you?
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Yes
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No
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If not, choose
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Vaccinate today at a cost of $14.00 - $19.50
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Call previous veterinarian for tag number
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Are you bringing previous vaccine history with you?
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Yes
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No
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If not, would you like to have your records faxed and added to your PetDocks medical record?
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Yes
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No
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Thank you for choosing PetDocks Veterinary Hospital as your veterinary care provider. We are committed
to your pet’s treatment being successful. Please understand that payment of your bill is considered part
of your pet’s treatment. The following is a statement of our Financial Policy.
All clients must complete our New Client & Patient Information forms before seeing the doctor.
The owner, or agent acting as owner, of any pet treated at PetDocks Veterinary Hospital is responsible for full
payment.
FULL PAYMENT IS DUE AT THE TIME OF SERVICE. WE ACCEPT CASH, CHECK, VISA,MASTERCARD,
DISCOVER, AMERICAN EXPRESS, CARE CREDIT.
Preferred Method of Payment:
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Cash
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Check
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Credit Card (Visa, Mastercard, Discover, American Express)
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Care Credit
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FOR AFTER-HOURS EMERGENCIES, PAYMENT MUST BE MADE IN CASH OR WITH A CREDIT CARD.
Estimates will be provided prior to any services, other than life-saving/resuscitative measures, being
performed.
In the event your account has to be turned over to our attorney or a collections agency, we reserve the
right to charge a collections fee of up to 50% of your account balance.
I understand every effort will be made to achieve a successful outcome and to provide for all possible
safety in hospital care and handling. I hereby authorize this hospital to receive, prescribe for, treat or
perform surgery upon the pet(s) listed and additional pets I present. Furthermore, I agree to pay fees for
services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated.
I agree to pay for the reasonable costs of collection in the event that collection efforts become necessary.
I understand that a service fee of $25.00 will be assessed for each non-sufficient funds check and/or
certified letter that must be sent. All accounts unpaid after 30 days receive a $5.00 Billing Charge each
month and a late charge computed at a periodic rate of 1.50% per month, which is an annual percentage
rate of 18.00% with a minimum monthly charge of $1.00. I understand that veterinary service is provided
during nighttime hours as necessary in the judgment of the veterinarian in charge. Continuous presence
of qualified personnel may not be provided. If I neglect to pick up my pet within 5 days of the discharge
date and do not notify you within that time period, you may assume that the pet is abandoned and are
hereby authorized to dispose of the pet as you deem best and/or necessary.
Thank you for understanding our Financial Policy. Please let us know if you have questions or concerns.
By submitting this form, you are digitally signing that:
- you are the person as identified as "client" on the first line of this form
- you have read, understand, and agree to the terms of the Financial Policy
- you are at least 18 years of age
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