ACAH Client Enrollment Form

Welcome to Apple Country Animal Hospital!

We’ll be happy to answer any questions you have about your pet’s health. By providing the following information, we will be able to establish a permanent record for your pet.
Owner's Name*

First NameLast Name
E-mail*
ex: myname@example.com
Primary Phone Number:*

Area CodePhone Number
Secondary Contact Number:

Area CodePhone Number
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Is There a Spouse/Partner/Family Member Who Should Be Listed On Your Account?

YesNo
Spouse/Partner/Family Member Name

First NameLast Name
Please tell us how the above person is related to you so we can refer to your relationship appropriately.
Spouse/Partner/ Family Member Contact Number:

Area CodePhone Number
How did you hear about us?*

Google (or other search engine)Social mediaNextdoor.comDrove by hospitalFriend/ReferralOther
Please tell us who we may thank for your referral!

Client Policies and Procedures

We want you to be aware of and understand the following policies and procedures for all clients.
We Love Social Media! Do we have your permission to post pictures of your pet(s), you and your pet(s) and/or your pet(s) and our team on Facebook?*

YesNo
Apple Country Animal Hospital uses email, text and our own hospital app for communications regarding our patient's reminders for health care needs. Do we have your permission to contact you via email, text and/or our app regarding these reminders?*

YesNo
FINANCIAL POLICY:

Our office accepts Visa, Mastercard, Discover, American Express and CareCredit. We also accept cash and checks.

We cannot offer in-house payment plans for our services. Clients needing additional financial support are encouraged to apply for CareCredit.

Full payment is due at the time of service. Our team is happy to provide any client with an estimate prior to services being rendered. Client will be responsible for a .03% monthly finance charge on accounts over 60 days old. Your signature below indicates your agreement with these policies.
TREATMENT CONSENT:

By signing this document, I declare I am the lawful owner of all listed pets and all information is true and correct to the best of my knowledge. I hereby authorize the veterinarian(s) of Apple Country Animal Hospital to examine, prescribe for or treat my pet(s) to the best of their abilities. I assume responsibility for all charges incurred in the care of this animal. I acknowledge that medical information will not be released to anyone not indicated on this form without my express verbal and/or written permission with the except of another veterinary facility.
*

Clear
Should be Empty:

Welcome to Apple Country Animal Hospital!

Client Policies and Procedures