Express Check In: New Client Intake Form Welcome! We are honored that you have chosen us to care for your pets. Tell Us About YourselfThis person(s) is the owner of record for the pet(s) below. They are the legal and financially responsible party and are authorized to make medical decisions for the pet(s).Name* First Last Co-Owner Name First Last Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email Primary Phone Number*Secondary Phone NumberWho can we thank for referring you? Google Our Website Facebook Instagram Other Name:Tell Us About Your PetName of your previous animal hospitalI give my permission for Aspen Grove Veterinary Care to request my pet's medical recordsYesNoPet Name*Breed*Color*Species*DogCatExoticExotic SpeciesWhat is your pet's approximate age?*( please include weeks / months / years)Sex*MaleFemaleSpayed FemaleNeutered MaleDo you have more pets? Yes No Pet NameBreedColorSpeciesDogCatExoticExotic SpeciesWhat is your pet's approximate age?( please include weeks / months / years)SexMaleFemaleSpayed FemaleNeutered MaleMedical Care DiscountsWe honor Senior Citizens (60 years +), and Military and Veterans with a 10% discount off our professional services (doctor time). Please mark which discount applies to you. Discounts do not apply to boarding and day care feesDiscountsSenior CitizenMilitary or VeteranAn ID will be required when you check your pet inPayment PolicyAcknowledgement* Our goal is to serve you and your pet in every way possible. This includes ensuring your medical team provides the level of care that fits within your budget. It’s important that your financial commitment and responsibilities are made clear before treatment begins. In the case of an emergency, your pet will be stabilized before your medical options are presented. Just like a human hospital, we offer a wide range of services, equipment and medicine in order to give your pet the best care possible. Our goal is to discuss all medical options with you and help you decide on a course of action for diagnostics and treatment. We are happy to provide written estimates at your request; simply ask your doctor, or any member of your medical team. If you are on a budget, let your doctor know as soon as possible so that we can customize a treatment plan for you. If your pet is hospitalized, half of the estimate is due prior to the start of treatment and final payment is due at the time of discharge. Full payment of your preliminary bill is due at the time services are rendered. For your convenience, we accept: Cash, Check, Mastercard, Visa, Discover, American Express, and Care Credit. Medical and boarding records are routinely audited to ensure accurate billing. While we do our best to ensure comprehensive billing when you check out, your account is not considered closed until an audit of the appointment or procedure has been completed. Similar to human hospitals, our medical and boarding records are routinely audited to ensure accurate billing for treatments and services rendered. Also similar to human hospitals, a final bill may be mailed reflecting audited charges. Owners have 30 days after receiving a final bill to pay their account in full. Late Cancellation & No Show PolicyAcknowledgement* To avoid fees, please arrive for your appointments on time and provide requested notice for cancellations. Late cancellation and no-show fees are required because we reserve time on the doctor’s schedule and provide skilled support staff just for you. With this acknowledgement, you agree to pay no show and late cancellation fees in accordance with our payment policies. Fees may added to your account and an invoice mailed to you. Failure to pay no-show and late cancellation fees may result in your account being sent to collections. We require a 3 day notice for surgical or dental cancellations and a 24-hour notice for appointment cancellations. Please plan ahead when scheduling appointments; late cancellation and no show fees apply in all situations. No Show & Late Cancellation Fees Appointment - $52 Surgical/dental - $200 Specialist - Fees vary Specialists Each specialist we use may have their own no show and late cancellation fees that may be charged in addition to Aspen Grove fees. We respectfully request that you be fully committed to the treatment plan before we schedule a specialist for you. At your request, we will be happy to find out what their no show or late cancellation fees may be before the appointment. BoardingA 5 day notice is required for a boarding cancellation. 50% of scheduled reservation will be due for late cancellation and 100% of scheduled reservation for boarding no show. Boarding Holiday Cancellation Policy (Thanksgiving and Christmas) We require a 10 day cancellation notice for all reservations in November – December (the Thanksgiving and Christmas holiday season). Cancellations without proper notification will be charged 50% of the boarding reservation. No shows will be charged 100% of the reservation. Prescription Refill PolicyAcknowledgement* Prescription Refills: Please plan ahead and allow 24 hours for your pet’s prescriptions to be refilled. A 24-hour notice is required to give your doctor time to review your pet’s medical record, make sure no changes are needed to the prescription, and approve the refill. In addition, it also gives our staff time to fill the prescription. For the safety of your pet, certain medications require blood testing and checkups at specific intervals in order for your pet to continue on the medication. Prescription Refunds: Any prescription medication that has left the building, regardless of whether or not it has been opened, cannot be returned. As all of our medications are regulated by the Federal Drug Administration (FDA) we are subject to the same dispensing laws as human pharmacies. Please remember that Heartgard is still a prescription item and falls under these regulations. Providing a written script after a prescription is already filled: Once you have requested a prescription refill, we will not provide a written script or approve an online request. We require you to pick up the prescription you requested to be filled. Bulk Rate Medications: In some cases we are able to offer clients a less expensive bulk option for chronic medications. A medication is considered ‘bulk’ when a client purchases the entire bottle. The bulk option is only available with a few medications. As we have minimal time spent with these orders any alteration to the order (including splitting pills) has an additional $10.00 charge to accommodate for staff time and our liability opening the bottle. Would you like to receive a copy of your intake form and policies acknowledgment for your files?* Yes No Email Signature*I acknowledge that I understand and agree to comply with all of the policies of Aspen Grove Veterinary Care.Name of person signing this form* First Last EmailThis field is for validation purposes and should be left unchanged.
