New Client Registration

Thank you for entrusting us with the care of your pet(s). So that we may be better able to meet your needs, please complete the following information:

Emergency Contact Information

Are they authorized to make medical/financial decisions on your behalf?

Are they 18 years of age or older?

Our clinic accepts Cash, Visa, MasterCard, American Express and Debit cards in addition to Care Credit and Scratchpay. We DO NOT accept personal checks. Unlike our counterparts in human medicine, we receive no financing from state or federal agencies, nor do we receive support from insurance companies or charities. It is for this reason that we require payment in full at the time services are rendered so that we can continue to operate a state of the art facility and provide your pet(s) with optimum health care. Deposits may be required for major medical/surgical cases or trauma and emergency work where hospitalization is required.

Financial Responsibility Agreement

I understand that if in the event my account becomes past due (over 30 days) a monthly Statement Handling Fee of $5 will be applied to my balance monthly and after 60 days an additional 2% service fee will be applied monthly. I understand that if my account becomes past due (over 90 days) and all attempts to arrange payment have failed, it will be turned over for collection. I also understand that I will be responsible for all applicable collection or attorney’s fees and all other costs expended to collect said amount. I also understand if in the event I pay by check* and it is returned for insufficient funds, I will be charged a fee of $35.00.

E-signature

Battlefield Animal Clinic has business and medical staffing hours as follows:

• Monday through Friday 6 AM to 7 PM

• Saturday 8 AM to 2 PM

• Sunday NO OFFICE HOURS

We typically have no continuous medical staff for the following hours:

• Overnight: Closing 7 PM to opening 6 AM

• Weekends:Closing Saturday 2 PM to Monday 6 AM

• Holidays: Closing time to opening day after holiday at 6 AM

• 1st Staff Meetings: 2nd and 4th Thursdays each month from 12 PM to 2 PM

Medical staff will be on-hand at these times on an “as needed” basis for any cases requiring continuous medical treatment. In the event of after-hours emergencies, please call the MedVet Emergency Hospital in Manassas at (703) 361-8287. The MedVet Emergency Hospital provides after-hours emergency care for our clients and will advise us of any emergency visits by our clients

E-signature

Date