Adobe Animal Hospital Patient Registration Form

CLIENT INFORMATION

PATIENT INFORMATION


AUTHORIZATION

RELEASE OF MEDICAL RECORDS : By initialing below, you authorize Adobe Animal Hospital to release your pet’s medical records (including doctor’s notes and lab results) when requested from pet insurance companies.


Do you authorize Adobe Animal Hospital to release your pet’s medical records for insurance purposes?


YOUR PET’S PREVIOUS RECORDS : Upon your request, we will electronically add records from previous hospitals to your pet’s medical file at Adobe. Please give your records to a Customer Service Representative at the front desk, where they will be scanned and then returned to you.


ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY : This information is accurate and true to the best of my knowledge. I understand that I am responsible to pay for services rendered at the time of service. I’m also responsible for reasonable attorney’s fees and costs of collection in the event of default. I further understand that if payment becomes 30 days past due, delinquency charges at the lesser of the annual rate of 18%, or the maximum allowable rate, will be due on delinquent amounts from the date the payment was due.


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ADDITIONAL CONTACT INFORMATION