Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Who else is authorized to make decisions about your pet's healthcare? *

First

Last

Phone

How did you find out about our hospital? If you were referred by someone, who should we thank? *

Name of previous veterinary clinic or doctor

City, State of previous veterinary clinic or doctor

May we request your pet's health records?

Yes
No

Would you like your pet's picture on social media? *

Yes
No

How would you like to be notified? *

Call
Text
Email
Postal

Payment in full is due at the time services are rendered. West Russell Animal Hospital does not offer any billing or payment plans. Certain procedures and services may require a deposit. The balance to be paid in full at the time of patient release. We accept Visa, MasterCard, Discover, Cash and Checks. All checks MUST HAVE a valid driver's license. We apologize for the inconvenience, but we DO NOT accept American Express, Care Credit or out of state checks. *

I have read the above written payment disclosure and accept full responsibility for all costs incurred. I understand that as a condition of treatment by West Russell Animal Hospital, any financial arrangements must be made in advance. In the event that this account should go unpaid, I understand that I will be subject to the cost of collections, including attorney fees and/or collection agency fees.

By clicking 'I agree', I acknowledge that I am 18 years of age or older and am fully responsible for all charges. *

I agree

Signature *

Please type your name.

Date *