To aid us in reaching an accurate diagnosis, a complete background on your pet is essential. Please fill out all pages of the following questionnaire to the best of your ability.
When was your pet last vaccinated against:
Treatment Authorization and Information
I hereby authorize VSNM practices to perform medical and initial diagnostic/surgical procedures in my pet as required for diagnosis and treatment. I understand that I can terminate treatment at any time by contacting the doctors and assistants.If I have been referred to this hospital by another veterinarian, I understand that they will require a summary of the care and treatment provided by the VSNM practices in order to ensure that my pet’s care can be continued without interruption. I also understand that VSNM considers the identification of a referring veterinarian by me to be my authorization to release records and information to that veterinarian. We are leaders and teachers in the veterinary medical field, thus case information and/or photos may be used in teaching, forms, continuing education, web site, veterinary literature, and the like. I authorize the release of case/patient information for such purposes; patient confidentiality (names withheld) will be maintained.In the event this animal transfers to ownership, I authorize release of medical information to the new owner, should they request it.
Payment is due as services are rendered. For hospitalized cases, a deposit is required in advance. The balance is due upon discharge from the hospital. You may pay by cash, personal check (with proper identification), or accepted credit cards. In order to avoid misunderstandings, please let us know immediately if these terms are not satisfactory.In the event payment is not made at the time of service, it is our policy to apply a service charge to accounts with a balance over 30 days old. A service fee of $3.00, and 1.5 % of the outstanding balance will be charged to your account monthly if not paid in full. All returned checks will incur a charge of $35.00 and may be referred to the District of Attorney for collection.
I understand that I (the owner or agent) am financially responsible to the applicable VSNM practice(s) for all charges relating to this patient. I have read and agree to the treatment authorization. I have also read and accept the financial obligations.
Type your full legal name above
Date Format: MM slash DD slash YYYY