Mt. Yonah New Client Form

Client Information
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question

    PET INFORMATION

    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question

    AUTHORIZATION

    I hereby authorize Mt. Yonah Animal Hospital to examine, prescribe for, and treat all pets owned by me and my family. I assume responsibility for all charges incurred in the case of my animal. I also understand ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.
    This is a required question
    This is a required question

    Financial Policy Acknowledgement Form

    Payment methods accepted are cash, Visa, MasterCard, Discover Card, Care Credit Card, and checks. The only exceptions to this policy are emergency cases or when prior arrangements are made and those situations will be handled on a case-by-case basis. We charge 1.33% interest monthly on all outstanding account balances older than 30 days. If you have an account 120 days past due, Mt. Yonah Animal Hospital may relinquish your balance owed to a collection agency. Mt. Yonah Animal Hospital charges $30 for returned checks. For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier. If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your pet. BY SIGNING BELOW, YOU AGREE TO THE FOREGOING TERMS OF PAYMENT AND TO THE FOLLOWING: I agree to pay all costs of collection, including reasonable attorneys' fees, and I further hereby waive all rights of exemption as to personal property under the Constitution and Laws of the State of Georgia.
    This is a required question