New Patient Intake Form - Compassionate Care Animal Hospital

Pet Owner's FIRST and LAST Name(Required)

It is important we have your full name (FIRST and LAST) so we can match your information with our records.

First Last

Pet Owner's Date of Birth(Required)

Pet Owners and any representative that brings in or otherwise makes decisions for the pet must be over eighteen years old.

Confirm the primary phone number for your account(Required)

This is the phone number where our staff will contact you to discuss your pet’s exam, diagnostic results, scheduling, and finances. (Note: We do not share this information outside of CCAH.)

Pet Owner's Driver's License State and Number(Required)

To expedite filling your pet's prescriptions, please provide your driver's license state and number. (If you choose to provide this at a later time, please note this can delay your pet's prescriptions when a driver's license is required by the State of Michigan and we do not already have it on file.)

Confirm the primary email address for your account(Required)

This is the email address where you will receive reminders, financial information, and general communications. (Note: We do not share this information outside of CCAH.)

Enter Email Confirm Email

Are you an existing client or a new client of CCAH?(Required)

Existing

New

How did you hear about our clinic?(Required)

Family / Friend

Internet Search

Social Media

Walked / Drove Past

Word of Mouth

Digital Ad

Print Ad

Radio Ad

Other

How did you hear about us?(Required)

Please provide the name of the family or friend who referred you.(Required)

We like to thank our clients who refer their wonderful friends and family!

Please provide your full home address(Required)

Street Address Address Line 2 City State ZIP Code

Would you like to add or update Pet Co-owner information?(Required)

Yes

Pet Co-owner Name(Required)

First Last

Pet Co-owner Phone Number(Required)

Would you like to add or update your emergency contact information?(Required)

Yes

Emergency Contact Name(Required)

First Last

Emergency Contact Phone Number(Required)

The following questions are important to update periodically so that we can provide the best care for your pet as they mature. Which pet are you telling us about?(Required)

Provide your pet’s name as it appears in our records. If you would like to include a nickname, please put the nickname in parentheses, e.g. Matilda (Mattie).

Describe your pet's diet and eating habits.(Required)

Nutrition and diet are key components of your pet's health. Even if you answered this for your last visit, it is essential to provide current information and to be as thorough as possible. Please include brand of food, type of food, frequency, and amounts.

If your pet has food allergies, please describe:

Does your pet behave like and/or do any of the following when entering or while in the carrier or the car?(Required)

Describe any other behaviors or actions not noted above that your pet exhibits in the car.(Required)

Describe any anxious, nervous, or other behaviors your pet exhibits in connection with visits to the veterinary hospital

If your pet has been medicated for previous vet appointments or travel, what medications were used, and how effective were they?

Describe any sensitive areas that your pet does not like to have touched

Has your pet had difficulty with any of the following procedures?(Required)

Nail Trims

Weight

Temperature

Ear Exam

Blood Draw

No history of difficulty with any procedures

Other

When has your pet had difficulty with procecures?(Required)

What types of treats does your pet prefer?(Required)

String cheese

Sliced cheese

Spray cheese

Peanut butter

Deli meat

Baby food

Cereal / Animal crackers

Other

What other treats does your pet prefer?(Required)

Please describe any treats that we should avoid using with your pet

If anyone in your household has food, medication, or other allergies, that we should be aware of when treating your pet, please list below:

Services Agreement

The following terms are intended to facilitate the expectations between you and CCAH so that we can all focus our efforts on a positive partnership to provide your pet optimal care. Please read the terms carefully. If you have questions about these terms prior to accepting them, send a detailed email to ccah@ccahpetvet.com and we will have the appropriate team member get back to you as quickly as possible.

Payments

PAYMENT is required at the time of service unless you have been notified by CCAH of other payment stipulations (such as a requirement to pre-pay for services or another payment option.) Payments accepted are Discover, Visa, Mastercard, American Express, Scratchpay, and Care Credit. Absent an alternative arrangement with CCAH, accounts older than 90 days will be turned over to a collections agency. This question is required.

Payments(Required)

As a reminder, CCAH is not accepting cash at this time.

I accept

I don't accept

Prescriptions

We have several options available for filling prescriptions. They are as follows:

1. Medications prescribed with an appointment may be filled same-day in-house or you may take a written prescription with you.

2. Our online web store may be used to order your prescriptions and have them shipped directly to you.

3. You may call the clinic to have medications we stock onsite filled for you. Allow 72 hours for all prescription refills.

4. Paper prescriptions are available to pick up and take with you to your local pharmacy to be filled. Allow 72 hours for all refill paper prescriptions.

5. We understand everyone forgets at times, so we offer a same-day refill for an additional $10 convenience fee.

6. If you require your prescription to be called into a pharmacy, we will offer this on a time available basis and for a $30 technican service fee. Please understand we strongly discourage this as we cannot guarantee the actions of outside pharmacies.

Prescriptions(Required)

I accept

I don't accept

Cancellation and No Show Policies

Last minute cancellations and no-shows prevent us from providing care to other patients. We understand that things come up and urge you to please notify us as soon as possible if you are unable to make your scheduled appointment time. Should you need to cancel last minute or if you do not show up for your appointment the following cancellation or no show fees will be assessed:

Appointments cancelled with less than 24 hours' notice are subject to a $30 fee.^

Surgeries cancelled with less than 24 hours' notice are subject to a $150 fee.^

No shows for appointments will be charged the full amount of the services scheduled. For example, if the appointment is for a wellness exam, the amount of the services would be the exam fee and does not include the fees for product charges such as vaccines, bloodwork, nor biohazard fees.

No shows for surgeries will be charged the full amount of the services listed as “low” on the surgical estimate. For example, if the estimate has a low of $500 and a high of $750, the fee will be equal to the $500 low estimate for services. The estimate for non-service items, such as anesthetic injectable medications are not included when calculating the no-show fee.

^Note: if appointments are cancelled due to illness during the pandemic, cancellation fees may be waived.

Cancellation and No Show Policies(Required)

I accept

I don't accept

Concerns

In order to help improve services at CCAH, I agree that all concerns regarding the clinic will be discussed with the appropriate CCAH personnel and CCAH will be given the opportunity to address and/or rectify the concerns before I post negative reviews.

Concerns(Required)

I accept

I don't accept

Communications

CCAH communicates important pet information, product recalls, wellness reminders, and urgent clinic updates (closures, electricity outings, and special events) via EMAIL. I agree to update my email address and understand that I am responsible to read emails sent to me from CCAH in order to stay informed about my pet’s medical needs and clinic information.

Communications(Required)

I accept

I don't accept

At CCAH, we love to share our adorable patients on social media. We only share photos and/or first names. Please let us know if you allow us to share your adorable pet on Facebook/Twitter/Instagram. If you are on social media, please follow us and watch for posts.(Required)

YES - feel free to post on social media!

NO - please do not post on social media

I understand that an estimate of the costs for veterinary services is available upon request. I am encouraged to discuss all fees attendant to such care before services are rendered and during this pet's ongoing medical treatment. In the event a pet is hospitalized for more than twelve hours and the attending doctor is unable to reach me, I understand it is my responsibility to call the hospital at least every 12 hours to inquire as to the medical status of my pet and the fees incurred for medical services up to that day.(Required)

I accept

I don't accept

I hereby consent to the examination of this pet by staff veterinarians. I understand that any procedure poses a risk, regardless of health status. In the event of unforeseen complications, I give permission for the doctors and staff to take reasonable measures in treating my pet and accept all charges that are incurred as a result of such action. I also agree that after consultation with me, the hospital's doctors may prescribe medication for, treat, hospitalize, sedate, anesthetize and/or perform surgery on this pet. I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made.(Required)

I accept

I don't accept

I acknowledge that I am the owner/appointed caregiver of this pet registered in my name at CCAH. I certify that I am over eighteen years of age. I have read, understand, and agree to each of the above accepted policies.(Required)

Annual Patient Intake Form

Services Agreement

Payments

Prescriptions

Cancellation and No Show Policies

Concerns

Communications