Step 1 of 3 33% 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 aboveSignature* 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.After Hours Exam Initial Payment: Prior to your pet’s examination by the neurologist, an initial payment of $357 will be collected. Initial AbovePayment at time of service: Payment is due in full at the time services are rendered. SCAN accepts Cash, Check, Visa, MasterCard, Discover, and American Express; but does not offer any payment plans.* Initial aboveDeposits: A security deposit equal to the low end of the estimate range will be required. The remainder of the invoice will be due upon patient discharge from the hospital.* 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 Scratchpay for alternative payment solutions for our clients. SCAN is in no way affiliated with CareCredit or Scratchpay; if you choose to utilize this plan, the financial relationship will be between 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 their 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 upon 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.* Initial aboveNon-payment of Services: Please note that if payment is not received in full at the time of discharge, your account will be subject to legal action.* 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 In order to better serve you, please take a moment to briefly tell us about your pet.*If your pet is on medications, we ask that you please bring all medications to your appointment.*What brings you in to see the Neurologist?*Pertinent Medical History (please include dates). If none please type N/A*Current Medications and Supplements (please include dosages). If none please type N/A*If none, please type N/APlease check off all symptoms that apply Fever Neck Pain Seizures Tremors Decreased Vision/Vision Loss Hearing Loss Circling Confusion Lethargy Aggression Nausea Abnormal Eye Movement Loss of Balance Fatigue/Muscle Weakness Phantom Scratching Loss of consciousness Fainting Incontinence Excessive thirst Excessive urination Weight loss Difficulty Eating/Swallowing Limb/Joint pain Change in bark Coughing Muscle spasms/Twitching Fainting Back Pain Clumsiness Gait changes Unprovoked Pain Pacing Insomnia Inappetence If your pet is having seizures, please notate date/time of all seizures. If none please type N/ACAPTCHA
