Intake Check-In

  • Client Information

  • Date Format: MM slash DD slash YYYY
    required for prescription medications
  • Patient Information

  • Behavior

    • Our staff does not tolerate rude or disrespectful behavior, such as yelling and/or use of profanity.
    • Anyone behaving in such a manner will be asked to leave.
    • Failure to comply may result in termination of patient/physician relationship.
    • The office supports the providers and staff who make decisions/recommendations regarding safe patient care. Compliance is encouraged by the patient. Repeated declination of provider recommendations may result in termination.
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  • Payment in full for all charges are required at time of service.

    It is understood that a treatment plan will be presented to me that will include any additional recommended treatments, diagnostics, or procedures and all cost associated with those services. I understand that no guarantee or assurance can be made as to the results that may be obtained. It is thoroughly understood that I assume all risks involved with any treatments or procedures. A deposit of the lower end of the estimated Treatment Plan is required in order to begin treatment of hospitalized patients. Payment in full of the remaining balance must be made when the patient is released. I am 18 years of age and/or over, I understand that I am authorizing care to the animal listed above and responsible for all costs that may be incurred.

    We accept cash, Visa, Mastercard, Discover and American Express credit cards, and bank Debit/ATM cards. We also accept Scratchpay and CareCredit financing.
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  • I have read the above terms and agree to comply.
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