New patient form - Alicia Pacific

New patient form

Tell Us About Your Furry Friends!

How Did You Hear About Us?

General Info

Preferred Payment Method
Do we have your permission to fax your and/or your pet’s medical records or vaccine information to boardingor grooming facilities, other veterinary hospitals, pet insurance companies, etc. if directly related to your pet’s care?
Do you have pet insurance? if yes, please present a claim form at the START of each vet visit.

The Fine Print

By sending the form I certify that I am the owner of the pet/s to be treated and authorize staff at The Country Vet to render anytreatment that is deemed necessary for my pet’s health. I am able to make medical and/or financial decisions about care. I understand that I may request an estimate for services recommended unless in emergency situations where the vets must act to save my pet’s life. I assume full financial responsibility for charges incurred and understand that payment IN FULL is required at the time services are rendered. If for some reason an account is not paid in full balances will accrue billing and interest fees andare subject to collection if not paid within 90 days.