WelcometoTumwaterVeterinaryHospital
NewPatientRegistration
Pleasenoteourhospitalpolicy:Allfees for service or productsaredueattimeofserviceorwhenthepatientisreleased.WeacceptCash,Checks,MasterCard,Visa,DiscoverandCareCredit.
Owner’s Name:
FirstMiddleLast
Physical Address: (Required) Street Number/Name City State Zip Code
Mailing Address: (If different from physical) Street Number/Name City State Zip Code
Phone:
(Phone #’s & Area Code Required)HomeCellWork
Driver’s License:
or Other Official Picture ID (Required) NumberState of Issue Expiration Date of Birth
Employer:______Employer Phone Number: ______
E-Mail:
Spouse/Partner: Spouse/Partner Phone:
Guarantor:
(If applicable)NameAddressPhone
Driver’s License:
or Other Official Picture ID (Required) NumberState of Issue Expiration Date of Birth
PET INFORMATION:
Pet’s Name: Dog ______Cat _____ Bird _____
Birthday: Male Neutered Female Spayed
Breed: Color: ______Hair Type: Long Medium Short
--Additional Pages Are Available for Multiple Pets--
Is there anyone else who is authorized to seek treatment for your pet? If “Yes”list below:
1. Phone:
2. Phone:
IhavereadandunderstandtheTumwaterVeterinaryHospitalPolicyandagreetoalltermsandconditionstherein:
Owner/Client SignaturePrinted NameDate
Guarantor Signature (If applicable)Printed NameDate
Revised 10/15/15awc approved by GB 12/18/13
FinancialPolicy
ThankyouforchoosingTumwaterVeterinaryHospital.Ourprimarymissionistodeliverthebestandmostcomprehensiveveterinarycareavailableforyourpet.Animportantpartofthemissionismakingthecostofoptimalcareaseasyandmanageableforourclientsaspossibleatthetimeofdischarge.
PaymentOptions:
- Cash,checkanddebit
- Visa,MasterCardandDiscovercreditcards(sorry,noAmerican Express)
- For balances over $250, monthly paymentoptionsfromtheCareCredit®HealthcareCreditCard* - qualification necessary.
DepositBilling:
If a Tumwater Veterinary Hospital estimate or course of care reflectsthe need forcomprehensivecareofyourpet,wewill requireadeposittobeginyourpet'streatment. Careplans/estimatesof$250.00ormorerequireaminimum50%deposittobeginyourpet'streatment.Certain treatments require full payment in advance. Afeeof1%interestpermonth(12%perannum)willbechargedonalloutstandingaccountbalances60daysormorepastdueaswellasbalancesunderanypaymentorheldcheckplan.Ifyour account becomes90dayspastdue,TumwaterVeterinaryHospitalmayassignyouroutstanding balancetoa collections company in the State of Washington.Intheeventlegalactionshouldbecomenecessarytocollectanyunpaidbalance(s)dueforveterinaryservicesrenderedbyTumwaterVeterinaryHospital,theclient/guarantor/designatedpayor(s)agreethat anylegalactionor collectionactivityeitherfromTumwaterVeterinaryHospital, anassignedcollectionagency or any other legal entity willbeinThurstonCountyintheStateofWashington.Client/guarantor/designatedpayor(s) whoresideormoveoutside of Thurston County or are ina"closedborderstate"agreetosubjugationtolegalorcollectionagencyaction inThurstonCountyinthestateof Washingtonratherthanhavetheseactionstransferredorassignedtoalocal collectionagencyorjurisdictionwithinthecounty or stateinwhichtheclient/guarantor/designatedpayor(s)reside.
AdditionalPolicyInformation:
TumwaterVeterinaryHospitalcharges$48.50for each returnedcheck.(We reserve the right to increase the returned check fee without notice). Returned checks must be paid in full along with the returned check fee within five working days of verbal, written or electronic notification by Tumwater Veterinary Hospital management or the account will be assigned to a collection agency within Washington State.
Forclientswithpetinsurance,wearehappytoprovideyouwith thenecessarydocumentationtosubmitaclaimto yourinsurancecarrier or provide the carrier with information regarding a procedure should you require pre-approval from your insurer.
Bysigningbelow,you agreetotheforegoingtermsofpayment for all fees and services incurred:
Client SignatureDate
Client Name (Printed)
Guarantor/Designated Payor(s) Signature (If Applicable)Date
Guarantor/Designated Payor(s) Name (Printed)
TumwaterVeterinaryHospital
7020LittlerockRd.SWITumwater,WA985121Phone360-754-60081Fax360-754-6185
Revised 2/5/2015awc approved by GB 12/18/13