Patient Intake & Service Agreement Form

Client Intake

Formatted Paragraph

Please complete this form if you are either:
1) a current patient and have not completed this form in the past year, or 2) a potential new patient.* *Please note that new patient appointments are currently being scheduled about three weeks from the date of submission of this form. Once you have submitted this form, please call us during business hours at 734-436-0455to schedule your new patient appointment. If you would like to request more urgent care, please let our staff know at that time.

General Information

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)

MM slash DD slash YYYY

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!

Has any of your contact information changed?(Required)

Yes

Please provide your full home address:(Required)

Street Address Address Line 2 City State ZIP Code

Do you have any allergies to food that we should be aware of?(Required)

We use food during our Fear Free appointments and we want to ensure your safety as well as your pet's.

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)

Does your pet's co-owner have any allergies to food that we should be aware of?(Required)

We use food during our Fear Free appointments and we want to ensure your co-owner's safety as well as your pet's.

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 periodically update 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:

As a Certified Practice, it is important that we have the most up to date behavioral information for your pet.

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

Visit anxiety may begin when pets enter the carrier or car.

Eager / Excitement

Subdued

Reluctant

Bark / Meow

Hide

Whine

Drool

Pant

Vomit

Tremble

Urinate / Defecate

Pace

Other

N/A

Describe the behaviors or actions not noted above that your pet exhibits in the car:

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 procedures?(Required)

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

These are the treats we commonly have available at CCAH. If your pet prefers a treat not listed below, please consider bringing it with you to your appointment. As a reminder, please bring your pet hungry.

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:

Service 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. (Required)

As a reminder, CCAH is not accepting cash at this time.(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 (https://ccah.ourvet.com/pet/) may be used to order your prescriptions and have them shipped directly to you. (Please note that any prescription food or medication requests made on any other third party vendor's website will be assessed an $18 fee.)

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 technician service fee. Please understand we strongly discourage this as we cannot guarantee the actions of outside pharmacies. (Required)

*Please note that we do not honor prescriptions requested through Amazon Pharmacy.

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 contagious illness, cancellation fees may be waived. (Required)

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. (Required)

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. (Required)

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)

Social Media(Required)

YES - feel free to post on social media!

NO - please do not post on social media

Estimates

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)

(Required)

I accept

I don't accept

Examination Consent

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)

(Required)

I accept

I don't accept

Global Agreement

By providing my birthdate again below, 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)

Date(Required)

MM slash DD slash YYYY

Please enable JavaScript in your browser to complete this form.

Formatted Paragraph

Please complete this form if you are either:
1) a current patient and have not completed this form in the past year, or 2) a potential new patient.* *Please note that new patient appointments are currently being scheduled about three weeks from the date of submission of this form. Once you have submitted this form, please call us during business hours at 734-436-0455 to schedule your new patient appointment. If you would like to request more urgent care, please let our staff know at that time.

General Information

Owner Details

Pet Owner's FIRST and LAST Name: *

First

Last

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

Pet Owner's Date of Birth: *

Primary phone number for your account: *

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: *

Primary email address for your account: *

Confirm Email

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.)

Are you an existing client or a new client of CCAH? *

Existing
New

provide diet of

How did you hear about our clinic? *

Family/Friend
Internet Search
Social Media
Walked/Drive Past
Word of Mouth
Digital Ad
Other

How did you hear about us? *

Please provide the name of the family or friend who referred you: *

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

Has any of your contact information changed? *

Please provide your full home address: *

Address Line 1

Address Line 2

City

State

Zip Code

Do you have any allergies to food that we should be aware of? *

We use food during our Fear Free appointments and we want to ensure your safety as well as your pet's.

Would you like to add or update Pet Co-owner information? *

Pet Co-owner Name: (copy) *

First

Last

Pet Co-owner Phone Number: *

Does your pet's co-owner have any allergies to food that we should be aware of? *

We use food during our Fear Free appointments and we want to ensure your co-owner's safety as well as your pet's.

Would you like to add or update your emergency contact information? *

Emergency Contact Name: *

First

Last

Emergency Contact Phone Number:

Your Pet's Details

The following questions are important to periodically update so that we can provide the best care for your pet as they mature.

Which pet are you telling us about? *

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: *

If your pet has food allergies, please describe:

As a Fear Free Certified Practice, it is important that we have the most up to date behavioral information for your pet.

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

Eager/Excitement
Subdued
Reluctant
Bark/Meow
Hide
Whine
Drool
Pant
Vomit
Tremble
Urinate/Defecate
Pace
Other
N/A

Describe the behaviors or actions not noted above that your pet exhibits in the car: *

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? *

Nail Trims
Weight
Temperature
Ear Exam
Blood Draw
No history of difficulty with any procedures
Other

When has your pet had difficulty with procedures? *

What types of treats does your pet prefer? *

String cheese
Sliced cheese
Spray cheese
Peanut butter
Deli meat
Baby food
Cereal/Animal crackers
Other

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:

Service Agreement

Payments

PAYMENT is required at the time of service unless you have been notified by CCAH of other payment stipulations *

I accept
I don't accept

As a reminder, CCAH does not accept cash.

Prescriptions

Please note that we do not accept returns on prescriptions. This is in accordance with section R338.503 of Michigan's Administrative Code that states that prescription drugs that have been dispensed and have left the control of the pharmacist must not be returned or exchanged except in instances of 1) the wrong medication being dispensed to the patient or 2) a drug recall.

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

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

  Our online web store VetCove may be used to order your prescriptions and have them shipped directly to you. Please note: requests made through any other third-party pharmacy will incur an $18 processing fee per prescription request.

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

  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.

  We understand everyone forgets at times, so we offer a same-day refill for an additional $10 convenience fee.
  If you require your prescription to be called into a pharmacy, we will offer this on a time-available basis and for a $30 technician service fee. Please understand we strongly discourage this as we cannot guarantee the actions of outside pharmacies. *

→    Please note that we do not honor prescriptions requested through Amazon Pharmacy.

Acceptance of Prescription Terms *

I accept
I don't accept

Cancellation and No Show Policies

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 contagious illness, cancellation fees may be waived. *

Acceptance of Cancellation Terms *

I accept
I don't accept

Concerns

Acceptance of Concerns Terms *

I accept
I don't accept

Communications

Acceptance of Communications Terms *

I accept
I don't accept

YES - feel free to post on social media!
NO - please do not post on social media

Estimates

Acceptance of Estimates Terms *

I accept
I don't accept

Examination Consent

Exam Consent *

I accept
I don't accept

Global Agreement

By typing my name below, 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. *

Full Name as Signature *

Full Name as Signature

Client Intake

Formatted Paragraph

General Information

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)

MM slash DD slash YYYY

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)

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!

Has any of your contact information changed?(Required)

Yes

Please provide your full home address:(Required)

Street Address Address Line 2 City State ZIP Code

Do you have any allergies to food that we should be aware of?(Required)

We use food during our Fear Free appointments and we want to ensure your safety as well as your pet's.

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)

Does your pet's co-owner have any allergies to food that we should be aware of?(Required)

We use food during our Fear Free appointments and we want to ensure your co-owner's safety as well as your pet's.

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 periodically update 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)

If your pet has food allergies, please describe:

As a Certified Practice, it is important that we have the most up to date behavioral information for your pet.

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

Visit anxiety may begin when pets enter the carrier or car.

Eager / Excitement

Subdued

Reluctant

Bark / Meow

Hide

Whine

Drool

Pant

Vomit

Tremble

Urinate / Defecate

Pace

Other

N/A

Describe the behaviors or actions not noted above that your pet exhibits in the car:

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 procedures?(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:

Service Agreement

Payments

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

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.

*Please note that we do not honor prescriptions requested through Amazon Pharmacy.

Prescriptions(Required)

I accept

I don't accept

Cancellation and No Show Policies

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.^

^Note: if appointments are cancelled due to contagious illness, cancellation fees may be waived. (Required)

Cancellation and No Show Policies(Required)

I accept

I don't accept

Concerns

Concerns(Required)

I accept

I don't accept

Communications

Communications(Required)

I accept

I don't accept

Social Media(Required)

YES - feel free to post on social media!

NO - please do not post on social media

Estimates

(Required)

I accept

I don't accept

Examination Consent

(Required)

I accept

I don't accept

Global Agreement

Date(Required)

MM slash DD slash YYYY

Patient Intake & Service Agreement Form

Client Intake

General Information

The following questions are important to periodically update so that we can provide the best care for your pet as they mature.

As a Certified Practice, it is important that we have the most up to date behavioral information for your pet.

Service Agreement

Payments

Prescriptions

Cancellation and No Show Policies

Concerns

Communications

Estimates

Examination Consent

Global Agreement

General Information

Owner Details

Your Pet's Details

Service Agreement

Payments

Prescriptions

Cancellation and No Show Policies

Concerns

Communications

Estimates

Examination Consent

Global Agreement

Client Intake

General Information

The following questions are important to periodically update so that we can provide the best care for your pet as they mature.

As a Certified Practice, it is important that we have the most up to date behavioral information for your pet.

Service Agreement

Payments

Prescriptions

Cancellation and No Show Policies

Concerns

Communications

Estimates

Examination Consent

Global Agreement

Book Your Pet’s Appointment Online