Client Name (person): Patient Name (pet):Address: Species: Breed: Home Telephone Number: Cell Phone Number: E-Mail for primary client contact: By providing your e-mail address, you give VSEC permission to contact you via e-mail with items such as surveys, photos of your pet, financial updates, medical updates, newsletters and pet health news/alerts. Driver’s License State and Number: Has this pet previously been to this practice? Yes No(If yes, do you recall which doctor you saw?)Communication with your primary care veterinarian is of the utmost importance. Please verify the name of your primary care veterinarian for your upcoming visit so that we can report our findings to them. Doctor: Hospital:Is the Veterinarian who referred you to our practice the above Doctor? Yes No(If no, who is the doctor that referred your pet to be seen today?Who is the veterinarian that will see your pet for yearly visits and vaccinations?Is your pet current with vaccinations? Yes NoDo you have a vaccination certificate? Yes NoHow were you referred to us for this visit? My Veterinarian referred me. The staff at my Veterinarian’s office referred me. I received your information from my Veterinarian’s answering machine. Previous visit. General knowledge. OtherPayment PolicyOur mission is to deliver the finest, most cost effective health care treatment available today. Following evaluation, the doctor will advise you of our plan for treatment. Additionally, we will discuss with you the cost of today’s treatments and the estimated cost for future treatments. Payment is due when the services are rendered. We are sensitive to the fact that it may be difficult to pay cash for your pet’s tests and treatment. Therefore, we offer several payment options for your convenience.PAYMENT OPTIONS1. Cash or Check – We use TeleCheck Electronic Check Processing; this requires a valid driver’s license. By paying by check, you authorize us or our agent to use information from your check to process a one-time Electronic Funds Transfer (EFT) or a draft drawn from your account, or to process the payment as a check transaction. When we use information from your check to make an EFT, funds may ne withdrawn from your account as soon as the same day you make your payment and you will not receive your check back from your financial institution. If your payment is returned unpaid, you authorize the colelctions of your payment and a return fee of $30 by EFT(s) or draft(s) drawn from your account.2. MasterCard, Visa, Discover, or American Express3. CareCredit® Monthly Payment Plans – This is a health care credit card that you may use after completing an application. Processing your application will only take a few minutes. There are no annual fees and monthly payments need only be 3% of the monthly outstanding balance. Please ask the receptionist for an application if you are interested in this method of payment. Two forms of identification are required from the applicant(s), one of which must be a current driver’s license, picture state identification or military identification card. After your application is processed, you will receive a CareCredit® card in the mail that can be used anywhere that accepts this payment, including your local pharmacy or family healthcare provider. Billing will be made directly by CareCredit® as with any credit card company. The following CareCredit® payment plans are offered at VSEC:Transactions are interest free for 6 months if you pay the balance in full by the 6th month.· Transactions over $1,000: 24, 36 and 48-month extended plans are available with fixed monthly payments at 14.9% from the date of transaction.· Transactions over $2,500: a 60-month extended plan is available with fixed monthly payments at 14.9% from the date of transaction.· With all of the above listed plans, if you are not able to pay the balance in full within that time or do not pay the minimum monthly payments, the interest rate is 26.99% and begins to accrue at the date of purchase.Required Deposit and Payment Policy: When your pet is admitted to the hospital, a deposit equal to 75% of the total estimated cost of treatment is required at that time. For extended hospitalizations, you will be contacted by the financial department and asked to bring your invoice up to date and/or make additional deposits as fees accumulate. The final balance for all services provided is due when your pet is discharged from the hospital.We require that your driver’s license number be kept on file for current or future check payments. We ask for this documentation upon your first visit to our hospital so that it may be placed in your record. Please indicate below the form of payment you prefer to settle your account: Cash or Check Visa, MasterCard, Discover or American Express CareCredit – Please visit www.carecredit.com if you would like to apply for credit prior to your visit. Please bring a hard copy of the approval with you to VSEC.