New Client Registration Date MM slash DD slash YYYY NameSpouse’s NameMailing Address Street Address City ZIP / Postal Code Home PhoneBest time to call AM PM E-Mail address EmployerPhone#If necessary, may we call you at work? Yes No Drivers License NumberStateSpouse’s Place of EmploymentPhone#How did you hear about us? Phonebook Hospital Sign Personal Referral Other If you were referred by someone, whom may we thank?Patient InformationPet’s Name Dog Cat Horse Other BreedSex Male Female Spayed/Neutered ColorDate of Birth/AgeWhen was your pet last vaccinated? Dog Cat Horse Distemper/ParvoDistemper comboFlu/RhinoRabiesRabiesTetanusLeptoWest NileLeukemiaBordatellaFIPSleeping SicknessOther vaccination(s):Approximate date(s) givenPrevious Veterinarian Street Address City State / Province / Region What is your pet’s current medical conditionDoes 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:SignatureFinancial PolicyThank 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® CreditCardDeposit & 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 SignatureDate MM slash DD slash YYYY Client/Owner Name (Please Print)
