Client-Patient Information Form in Michigan City, IN

Client-Patient Information Form

Thank you for giving us the opportunity to care for your pet(s). Please help us meet your needs better by taking a few moments to complete each of the information sheets.

Date:

Owner's Name:*

First Last

Co-Owner's Name:*

First Last

Owner's Address:

Street Address City State / Province / Region ZIP / Postal Code

Home Phone:

Work Phone:

Cell Phone:

Co-Owner's Home Phone:

Co-Owner's Work Phone:

Co-Owner's Cell Phone:

E-mail Address:*

Driver's License:

Employer:

Co-Owner's Employer:

Preferred Method of Contact:

How did you first hear of our hospital?

Whom may we thank?

Name of other business:

Animal Information/Medical History

Pet #1

Name	Species	Breed	Color

Age/ DOB	Sex	Spayed/Neutered

Prior Illness:	Prior surgery not including altering:	Date of last Vaccines & Clinic done at:

Pet Insurance Company:

Pet #2

Name	Species	Breed	Color

Age/ DOB	Sex	Spayed/Neutered

Prior Illness:	Prior surgery not including altering:	Date of last Vaccines & Clinic done at:

Pet Insurance Company:

Pet #3

Name	Species	Breed	Color

Age/ DOB	Sex	Spayed/Neutered

Prior Illness:	Prior surgery not including altering:	Date of last Vaccines & Clinic done at:

Pet Insurance Company:

Notification/ Agreement

To prevent the spread of infectious diseases and parasites, hospitalized and medical boarded animals must be current on all vaccines and free of internal and external parasites. I authorize the Animal Clinic of Michigan City to provide vaccines and parasite control as needed for my pet. I am financially responsible for the patient(s) described above and agree to pay all fees incurred. I understand that any medical or surgical procedure is attended by some risk and that it is not possible to guarantee that successful outcome of any such procedure. This agreement is in force indefinitely from this date unless notify Animal Clinic of Michigan City in writing on the contrary.

Authorization for release of medical records.

I authorize the Animal Clinic of Michigan City to acquire any and all medical or surgical records from my previous veterinarian and /or send such information to any veterinarian and/or pet boarding/ grooming facility as requested by us or them

Appointment Cancellation/ Late & Reschedule Policy Agreement

Animal Clinic of Michigan City is committed to providing all of our patients with exceptional care. When a patient cancels without giving enough notice, they prevent another patient from being seen.

Please call us at 219-879-0249 by 3:00pm on the day prior to your scheduled appointment to notify us of any changes or cancellations. To cancel on a Monday appointment, please call our office by 3:00 pm on Friday. If prior notification is not given, you will be charged $25.00 for the missed appointment.

If you are more than 15 minutes late to your scheduled appointment you will be responsible for a $10.00 late fee and will be seen as a work in (work in can mean anytime from your original appointment to the time we close).

If you are more than 20 minutes late to your scheduled appointment you will need to reschedule and will be charged a $25.00 service charge.

PHOTO CONSENT

I grant to Animal Clinic of Michigan City, its representatives and employees the right to take photographs of me/ or my pet, and to copyright, use and publish the same in print and or electronically. I agree that Animal Clinic of Michigan City may use such photographs of me and or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content.

Check One:

I GIVE permission to the Animal Clinic to use photos of me and or my pet
I DO NOT permission to the Animal Clinic to use photos of me and or my pet

PAYMENT INFORMATION

Payment is due in full at the time services are rendered
This office does NOT do any billing, we do NOT offer payment plans
We accept the following forms of payment:
• Visa
• MasterCard
• Discover
• American Express
• Care Credit
• Cash

We accept personal checks with a valid Driver’s License or Social Security Number. There is a $25 fee for all returned checks.

Please print and sign below that you are taking responsibility for full payment of treatment and services for the pets you are bringing in to Animal Clinic of Michigan City, at the time they are treated. If you are not the individual who is financially responsible for these pets, by signing this form you are stating that you have made prior arrangements with the individual who is. I agree to absolve the Animal Clinic of Michigan City, veterinarian, and staff employed by the practice of any financial consequences that may occur between you and the other individual you have made prior arrangements with.

Signature

Date

Comments

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