Patient/client Information Sheet - Knowles Animal Clinic (Page 2 of 2) in pdf

HOW DID YOU HEAR ABOUT KNOWLES ANIMAL CLINICS?

A friend? – Whom may we thank?:_______________________________________________________

CHOOSE ONE: Clinic Sign/Drive by

Internet/Google

Community Activity

PLEASE READ OUR FINANCIAL POLICY CAREFULLY

Our intention is to provide you with a written treatment plan required for emergency care, in-clinic treatment,

surgery and/or hospitalization. A deposit is required prior to any treatment and for all hospitalized animals.

Hospital accounts must be kept current throughout the period of hospitalization. If your pet is admitted through

the Emergency Clinic, you will receive a treatment plan for your emergency clinic costs. The Emergency Clinic

collects these charges. If additional treatment and hospitalization is necessary, a second treatment plan will be

required and the charges will be collected by the Day Clinic furnishing the follow-up care of your pet. It is your

responsibility to make sure you are aware of the costs involved with treatment.

ALL CHARGES ARE DUE PRIOR TO RELEASE OF YOUR PET

POLICY CONCERNING UNPAID BILLS/ABANDONED PETS:

If you do not pick up your pet within ten (10) days of its release date, your pet will be considered abandoned. Your

total bill (treatment charges and hospitalization charges got the ten (10) additional days), attorneys fees and court

costs, plus collection fees (40-50% of the bill) will be turned over to a national collection agency and reported to

the appropriate credit bureaus to be placed on your credit record.

DESIRED FORM OF PAYMENT (We DO NOT carry open accounts and hope these alternatives are convenient for

you).

WE ACCEPT: Cash, Check (with a driver’s license or I.D.), Mastercard, Discover, Visa, & American Express.

We also accept CARE CREDIT, which is our billing service. Please ask the receptionist for details.

CARE CREDIT must approve you in order to use this service.

PLEASE FURNISH THE FOLLOWING INFORMATION (The Driver’s License will be required for identification

purposes).

DRIVER’S LICENSE NUMBER: _____________________________________________________________

SOCIAL SECURITY NUMBER: ______________________________________________________________

I have read and understand the above policies and request treatment of my pet in accordance with these

policies. I understand medical results cannot be guaranteed. I assume financial responsibility for all

charges incurred to the patient and agree to pay all costs of collection, reasonable attorney fees and

court costs in the event of non-payment. To prevent the spread of infectious diseases and parasites,

hospitalized or boarded animals must be current on all vaccinations and be free of internal and external

parasites. I authorize Knowles Animal Clinics to provide vaccines and parasite control when needed.

DATE:________________ SIGNATURE:______________________________________________________

Patient/client Information Sheet - Knowles Animal Clinic Page 2