Step
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50%
Client Registration
Name
(Required)
DOB
(Required)
MM slash DD slash YYYY
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Home Phone
Cell Phone
(Required)
Email
(Required)
Employer
Employer Phone
Spouse Name
DOB
MM slash DD slash YYYY
Home Phone
Cell Phone
Employer
Employer Phone
I, the owner or authorized agent of the animals in this account, hereby authorize the veterinarians and staff of Silver Bluff Animal Hospital to examine, prescribe treatment for and preform procedures that are deemed medically necessary for the health of my animals in the event that I, the owner, or authorized agent , cannot be reached. I have read and fully understand this authorization for medial treatment responsibility. I give Silver Bluff Animal Hospital permission to fax, mail, or email my pet's records to other veterinary offices, boarding facilities and/or grooming facilities as needed.
Owner/Authorized Agent Signature:
(Required)
Date:
(Required)
MM slash DD slash YYYY
Financial Policy:
Payment options available are: Cash, Check, Visa, MasterCard, American Express, Discover, and Care Credit. Silver Bluff Animal Hospital does not hold checks or have a payment plan options. Silver Bluff Animal Hospital requires a payment in full at the end of your pet's examination and/or at the time of discharge. Treatments and medical care plans that are estimated to be greater than $500.00 will required a deposit of 50% at admittance and the balance due at discharge. A $35.00 returned check fee will apply to all returned checks and any returned check that is not reconciled within 5 business days of return, will be submitted to Aiken County Worthless Check Unit. Any client sent to collections for an unpaid balance will be required to pay the collection company in full and pay SBAH a reinstatement fee to resume services. By signing below you are confirming that you have read and understand the treatment agreement and financial policies of Silver Bluff Animal Hospital.
Owner/Authorized Agent Signature:
(Required)
Date:
(Required)
MM slash DD slash YYYY