E-Mail Address (required) Emergency Contact informtion
Check if same as above information Emergency Persons Relationship: Patient Infomation
Pet's Name (required) Pet Age: Years, Months Type of Pet (required) Breed: Sex: (required) Neutered/Spayed (required) Are your pets vaccines current? Veterinarian Information
Do you have pets medical records with you? Name of Referring Veterinary Practice & Name of Veterinarian (required) May we request a transfer of records? Please list any additional pets here - additional forms available at checkin. Just one question for helping us get the word out!
How did you hear about us? (required) (Please choose one ) Financial Terms
Please Read Financial Terms I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Evergreen Animal Hospital and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Evergreen Animal Hospital's collection agency, and will incur a 40% collection fee for which I am liable, in addition to monthly finance charges. I have read this statement and - (required) Drivers License #, State, Expiration (required) Emergency Care Directive
In case of an emergency Please allow Evergreen Animal Hospital (EAH) to make decisions for the care of my pet in case of an emergency. If my animal is transported to this facility, I will be responsible for all payments. Evergreen Animal Hospital will keep a copy of this form in our records. I have read this emergency care financial agreement and - Emergency Care Request Evergreen Animal Hospital will try to contact you as soon as possible if your pet is brought in as an emergency. If I cannot be consulted, I wish for Evergreen Animal Hospital to (Please mark only one) Choice of care THANK YOU Thank you for allowing Evergreen Animal Hospital to provide for your pets health care needs.
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