New Client Registration in Stephenville, TX | Cornerstone Animal Hospital

Date

MM slash DD slash YYYY

Name

Spouse’s Name

Mailing Address

Street Address City ZIP / Postal Code

Home Phone

Best time to call

AM
PM

E-Mail address

Employer

Phone#

If necessary, may we call you at work?

Yes
No

Drivers License Number

State

Spouse’s Place of Employment

Phone#

How did you hear about us?

Phonebook
Hospital Sign
Personal Referral
Other

If you were referred by someone, whom may we thank?

Patient Information

Pet’s Name

Dog
Cat
Horse

Other Breed

Sex

Male
Female
Spayed/Neutered

Color

Date of Birth/Age

When was your pet last vaccinated?

Dog
Cat
Horse

Distemper/Parvo

Distemper combo

Flu/Rhino

Rabies

Tetanus

Lepto

West Nile

Leukemia

Bordatella

FIP

Sleeping Sickness

Other vaccination(s):

Approximate date(s) given

Previous Veterinarian

Street Address City State / Province / Region

What is your pet’s current medical condition

Does your pet have any known allergies?

Yes
No

If yes, what are they ?

Is he/she on any medication?

Yes
No

If so, what kind?

What kind of food do you feed him/her?

Is there anything else we should know about your pet?

We occasionally share photos of our patients on our website, Facebook page, etc. If you would like to authorize us to share your animal's name and picture please initial here:

Signature

Financial Policy

Thank you for choosing Cornerstone Animal Hospital. Our primary mission is to deliver the best and most comprehensive veterinary care available for your pet or horse. An important part of the mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options. Cornerstone Animal Hospital requires payment in full at the end of your animal's examination and/or at the time of discharge.

Payment Options:

You can choose from:

Cash, Check, Visa®, MasterCard®, American Express® or Discover Card®
If you qualify, you may be eligible for Monthly Payment Options¹ from the CareCredit® CreditCard

Deposit & Billing:

For some treatments or hospitalized care, a deposit may be required. Healthcare plans requiring comprehensive care of $250 or more, will require a 50% deposit to begin your animal’s treatment. If circumstances dictate that we must carry an in-house balance, we will be forced to charge 1.5% interest per month (18% annually) on all outstanding account balances older than 30 days. If you have an account 90 days past due, Cornerstone Animal Hospital may relinquish your balance owed to a collection agency. All collection charges will be the responsibility of the client.

Additional Policy Information:

Cornerstone Animal Hospital charges $30 for returned checks. For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier.

If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your animal.

By signing below, you agree to the foregoing terms of payment:

Client/Owner Signature

Date

Client/Owner Name (Please Print)