Request Appointment - Happy Paws Animal Hospital

Owner's Name*

First Last

Co-Owner's Name

First Last

Address*

Street Address Address Line 2 City State ZIP / Postal Code

Driver's License Number*

Home Phone

Work Phone

Cell Phone*

Co-Owner Work Phone

Co-Owner Cell Phone

Please check one preferred contact number*

Home
Work
Cell
Co-Owner Work
Co-Owner Cell

Owner Email

Co-Owner Email

Pet Name*

Canine
Feline

Breed*

Color*

Gender*

Male
Female

Neutered/Spayed*

Yes
No

Age/Birthdate*

Terms and Conditions*

I AGREE

By checking this box, I agree that I am the owner or agent for the owner, of the pet I am presenting for evaluation today and have the authority to sign, comply, and consent to the procedures described to me as well as provide timely payment for services.

All professional fees are due at the time services are rendered, with a 50% deposit required to begin diagnostics and/or treatment. The balance is due at the time the patient is discharged from the hospital. We accept cash, all major credit cards, checks (with proper ID) and CareCredit. There will be a service charge for any check returned unpaid. We are unable to extend credit or to bill you later. We urge you to discuss all fees with the doctor before the services are performed. Estimates for cost of care are available upon request.

I have read and understand this authorization and consent. I have read and agree to the above financial policy; and I understand my financial obligation. Further, I agree to pay all reasonable attorney fees and all costs and expenses which may be incurred by a collection agency in the enforcement of this agreement. The initial fee for a client to be transferred to the collection agency is $25.

Information and/or photos may be used in teaching, continuing education, web site, veterinary literature, promotional materials, and the like. I authorize the release of case/patient information for such purposes; pet owner confidentiality will be maintained.