Online Client Information Form in Palm Coast, FL | Safe Haven Veterinary Hospital

How did you hear about our hospital?*

Thank you for giving us the opportunity to care for your pet. Please help us to meet your needs better by taking a moment to complete this information sheet.

Owner’s Name*

First Last

Spouse/Other

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Primary contact phone #*

Secondary contact phone #

Work phone

E-mail address*

Employer’s Name & Address

Patient Information*

Pet's Name	Sex	Spay/Neutered	Birth Date	Breed	Color	Vaccines & Date Given

Current Medications, if any, that my pet is on?

Emergency contact and phone #*

Due to the high volume of returned checks we are unable to accept personal checks from new clients.

FINANCIAL POLICY

Payment for services is due at the time services are rendered. Accepted payment methods are cash, credit card (VISA, M/C, AmEx), or Care Credit. If a written estimate is desired, one can be prepared upon request. A deposit may be required for surgery or hospitalization upon admission. A fee in the amount of $36.00 will be charged for any returned checks. A monthly billing fee of $5.00 per month will be charged on all unpaid accounts after the first 30 days. I agree that should my account become delinquent, I will be responsible for all collection costs, including but not limited to the outstanding balance, attorney fees, court costs, and interest at the rate of 18% per annum (1.5% per month).

APPOINTMENT POLICY

All of our appointments and procedures require careful planning and scheduling, it is critical that clients keep their appointments and arrive in a timely manner. In this way we are able to keep waiting room time to a minimum. We do attempt to confirm all appointments by phone and email, but often cannot reach everyone. If a patient is unable to keep an appointment, more often than not another patient could be given that time. Therefore, we kindly ask that if you are unable to keep your appointment, you give us the courtesy of notifying us as soon as possible, even if it is the same day.

Our cancellation policy is as follows:

1) We do not initially charge for missed appointments, but a record of it will be kept.

2) Any client missing 2 consecutive appointments will not be offered another appointment unless choosing to pay for the services in advance.

3) Any client required to pay for an appointment in advance under the terms of this policy, who then does not provide us 24 hours notice of cancellation regarding the prepaid appointment, agrees to forfeit the deposit. To prevent the spread of infectious diseases and parasites, hospitalized and boarded patients must be current on all vaccines and free of internal and external parasites. I authorize the doctor to provide vaccines and parasite control as needed for my pet. I also understand that if my pet has fleas and requires admission for care, it will be treated at my expense.

I have read and understand the above policies.

Signature*

Date*