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