Step 1 of 2 50% Title*Mr. & Mrs.Mr.Mrs.Ms.Dr.Name* First Last Employer Occupation Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneWork PhonePreferred number to be contacted on* Home Phone Cell Phone Work Phone Email* Additional Owner Emergency Contact* Phone*Approved Methods of Contact (check all that apply)* Home Phone Cell Phone Work Phone Email Text Message Primary contact phone number (select one)* Home Cell Phone Work Pet RegistrationPet's Name* Birthdate or Age of Pet Species* Canine Feline Sex* Male Female Spayed or Neutered* Yes No Not Sure Breed* Color* Precautions or allergies to be aware of with your pet?* Current on rabies?* Yes No Not Sure Primary Care Veterinarian’s Name* Primary Care Practice Name* Should my pet become unstable while under the care of SCAN and require cardiopulmonary resuscitation (CPR), including cardiac compression, defibrillation, positive pressure respiration, emergency drugs, or other emergency interventions, I request or decline such medical intervention as indicated below* REQUEST FOR CPR. Having requested such emergency procedures, I agree to be held responsible for a minimum resuscitation fee of $500.00 to pay for the services performed while staff members pursue treatment and try to reach me for further directions. DECLINE CPR, DO NOT RESUSCITATE MY PET We thank you for allowing us this opportunity to care for your pet. In order to provide the highest standard of care for our patients, we require that all fees are due at the time of service. For your convenience, Specialists in Companion Animal Neurology accepts the following forms of payment: cash, personal check, credit card (Visa, MC, Discover, AMEX) and Care Credit. A service charge of $40.00 will be incurred for any returned check. We routinely provide written estimates for all hospitalized patients and your medical care team will discuss that estimate with you prior to admission. I would be happy to have SCAN share photos of my pet & the progress made here at the hospital on their website(s) and general social media. We will gladly send you a notification if we use your photo so you can share it with friends & family. Initial aboveHow did you hear about us?* Primary Veterinarian Website Search Engine Social Media Word of mouth Signature* By entering my name above, I warrant the truthfulness of the information provided in this application.Date* MM slash DD slash YYYY Payment PolicyWelcome to Specialists in Companion Animal Neurology (SCAN) and thank you for choosing us as your veterinary neurology/neurosurgery care provider. Please feel free to contact our staff regarding the policies described below. To avoid any misunderstanding, please read, initial, and sign this payment policy before your pet’s treatment.Payment at time of service: We require all clients to have a credit card on file. SCAN accepts Cash, Check, Visa, Mastercard, American Express, Discover, CareCredit and Scratch Pay; but does not offer payment plans.* Initial aboveDeposits: A security deposit will be required (100% of the estimate’s high end) The remainder of the invoice will be sent first via email prior to your pet’s discharge appointment, the balance will be due in full at discharge. THE BALANCE ON ANY PAST DUE ACCOUNT WILL AUTOMATICALLY BE CHARGED TO THE CREDIT CARD WE HAVE ON FILE IF WE DO NOT HEAR BACK FROM YOU WITHIN 10 DAYS.* Initial aboveEstimates: Estimates include items that are likely to be required in the care and hospitalization of your pet. Please understand that the estimate is an estimate only, and the final cost may vary from the estimate provided. Our staff will make every effort to inform you of ongoing costs; however, it is your responsibility to ask a staff member for daily updates on your invoice.* Initial aboveAlternative Finance Plans: SCAN has partnered with CareCredit and Scratch Pay for an alternative payment solution for our clients. SCAN is in no way affiliated with CareCredit or Scratch Pay. If you choose to utilize these plans the financial relationship is with you and the lender, not SCAN.* Initial abovePet Insurance: SCAN helps initiate necessary forms with your pet insurance provider; however, because clients are reimbursed for their pet’s charges directly by the insurance company, SCAN does not get involved in insurance billing. Clients are responsible for paying the normal deposit (see deposit requirements above) prior to service and paying the bill in full at discharge, as well as submitting their own pet’s claim. The insurance company will be responsible for reimbursement to you directly per your pet’s insurance agreement. BALANCES OVER 30 DAYS WILL INCUR 1.5% INTEREST CHARGE MONTHLY. ANY NSF PAYMENT WILL INCUR A FEE OF $35. A 5% PROCESSING FEE WILL BE ASSESSED TO TRANSACTIONS WHERE THE ORIGINAL PAYMENT METHOD IS REQUESTED TO BE MODIFIED OR CHANGED FOR ANY REASON.* Initial aboveNon Payment of Services: IN THE EVENT OF DEFAULT WHERE IT BECOMES NECESSARY TO PLACE THIS ACCOUNT COLLECTIONS, THE UNDERSIGNED AGREES TO PAY ALL COSTS OF COLLECTIONS, INCLUDING ATTORNEY’S FEES AND COURT COSTS.* Initial aboveI, the undersigned, am presenting my pet for veterinary services at Specialists in Companion Animal Neurology and understand the policies as described above.Signature* By entering my name above, agree to all of the listed policies.Date* MM slash DD slash YYYY CAPTCHA
