Owner's Name Name * Address * Day-Time Phone * Evening Phone Mobile Phone Email * Co-owner's Name & Contact # Name Phone How did you find out about our practice? If Other, please specify: If Personal Referral, is there someone we can thank for this referral? Please use this area to give us any other relevant information about yourself or your family Pet Information Pet's Name * Species * Dog Cat Rabbit Ferret Bird Reptile or if other species Breed (if known) Color Date of Birth or Age (if known) Special Identification (tattoo, microchip, etc.) Sex Neutered Male Spayed Female Male Female Unknown Previous Veterinary Practice (if any) Previous Veterinarian (if any)
Payment is expected in full when services are rendered. Accepted methods of payment are cash, checks, American Express, Discover, MasterCard, Visa, Scratchpay and Care Credit. Payment plans are NOT available. There will be a $50 fee for any returned checks and a 1.5% finance charge per month (18% APR) on outstanding balances. Should your account be placed for outside collections, you will be chared reasonable collection costs which may include but NOT limited to, collection agency fees, court costs, attorney fees, etc. **By submitting this form, I also grant St. Francis Animal Hospital permission to use my pet's picture and name on social media
St. Francis Animal Hospital is a full-service veterinary medical and surgical facility. We have business and medical staffing hours as follows: Monday-Friday 8:00 am to 6:00 pm Saturdays 8:00am to 3:00 pm Closed on Sundays and HolidaysTherefore this disclosure form is provided to inform you that we have NO in-house, on-duty continuous medical staff as follows: Overnight, from closing time at 6:00 pm to opening at 8:00 am. Weekends from closing on Saturday at 3:00 pm to opening on Monday at 8:00 am. Holidays, falling on Monday, from closing Saturday at 3:00 pm to opening on Tuesday at 8:00 am. There is, however, a trained staff member who will be checking all hospitalized patients during the hours that the hospital is not fully staffed. That schedule is determined by the attending doctor and may vary with the needs of the individual patient. If you have any questions concerning this policy, please don't hesitate to ask. Also, if you would like continuous overnight care of your pet, discuss those options with the doctor or technician.
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