Client Information: About You

Name: *

First

Middle

Last

Spouse's Name:

First

Middle

Last

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone: *

Spouse's Phone:

Email: *

May we use this email to send you reminders?

Yes
No

Social Security Number:

Driver's License:

Place of Employment: *

Employer Phone:

Spouse's Place of Employment:

Spouse's Employer Phone:

Who should we contact in case of emergency while you are here? *

First

Last

Phone: *

How did you find out about our hospital? If you were referred by someone, who should we thank? *

How would you like us to contact you?

Text
Call
Email

Reason for leaving previous veterinarian:

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Color *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Previous Veterinarian

Records Provided

Current Medications

Any serious illness or surgery

Any known allergies

Diet

I hereby authorize the veterinarian to examine, prescribe for and/or treat my pet(s). I assume responsibility for all charges incurred in the care of my animals. I also understand that these charges must be paid for at the time of release and that a deposit may be required. *

I accept

Signature *

Clear Signature

Today's Date *

Payment Method

Cash
Check
Mc/Visa/Discover
CareCredit

FINANCIAL POLICY AND RECORDS RELEASE

Thank you for choosing Mancelona Veterinary Hospital for your pet care needs. We are dedicated to providing the highest quality care to all of our patients.

In order to provide you services with the highest level of quality, we cannot extend credit out of our office. Please understand that payment in full is due at the time of service. We may also require a deposit for major procedures. To help you obtain your financial responsibility the following payment options are accepted.

PAYMENT OPTIONS

Cash/Check: We accept payment by cash at the time of service. We also accept payment by check (if a valid driver’s license number or state ID number, along with birth date is provided).
Bank Credit/Debit Card: We accept payment by MasterCard, Visa, Discover, and American Express.
In an effort to offer our clients more personalized financial arrangements, we are pleased to offer CareCredit. If you wish to take advantage of this payment plan, please apply online at www.carecredit.com
We are also pleased to offer Scratch Pay. To apply, please go to https://scratchpay.com.

RECORDS RELEASE

By signing this form, I authorize Mancelona Veterinary Hospital to release my pet’s medical and vaccine records, if requested, by another veterinarian, boarding facility, or grooming facility. I acknowledge that Mancelona Veterinary Hospital will not have me sign any additional paperwork to release my pet’s records. However, I might be required to sign paperwork to have records transferred to Mancelona Veterinary Hospital.

Bank Credit/Debit Card: We accept payment by MasterCard, Visa, Discover, and American Express.

In an effort to offer our clients more personalized financial arrangements, we are pleased to offer CareCredit. If you wish to take advantage of this payment plan, please ask one of our staff members for an application.

We are also pleased to offer Scratch Pay. To apply, please go to https://scratchpay.com.

I HAVE READ, UNDERSTAND, AND AGREE TO THE ABOVE FINANCIAL POLICY AND RECORDS RELEASE POLICY. *

Clear Signature

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Date *

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Client Information: About You

FINANCIAL POLICY AND RECORDS RELEASE

PAYMENT OPTIONS

RECORDS RELEASE

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