Referral Registration Form If your veterinarian referred your pet to us for specialty or emergency care, please complete the Referral Registration Form. This allows us to coordinate with your primary vet and ensure continuity of care. Referral Registration Form Client Information Name * Name First First Last Last Email * *Information will not be sold or shared for mass email purposes -for hospital use only Primary Phone * Secondary Phone Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Employer Work Phone Secondary Owner Phone Emergency Contact * Phone * Pet Insurance Carrier Policy Number Patient Information Pet's Name * Species * Breed * Pet's Color * Age/Date of Birth * Sex * MaleNeutered MaleFemaleSpayed Female Does your pet have a microchip identification? * Yes No What is the microchip number? Referring Veterinarian Information Veterinarian * Hospital/Clinic Name City Phone * plus1 Add Veterinarian minus1 Remove Veterinarian Was the pet/patient directly referred to CSAH by a veterinarian? * Yes No Do you have a Primary Care Veterinarian you will be returning to? Yes No Referral Policy You have been referred here by your Primary Care Veterinarian for emergency care and/or specialty care OR you were not directly referred but have indicated you will be returning to a Primary Care Veterinarian. Please be aware that we will only treat your pet’s present problem. For Primary Care, (i.e. wellness visits, vaccines, boarding, bathing, etc.) we will refer you back to your Primary Care Veterinarian for those services. Your cooperation is appreciated. Consent * I have read and understand the Referral Policy. Signature * signature keyboard Clear Date * Payment Policy ALL FEES FOR PROFESSIONAL SERVICES ARE DUE AND PAYABLE AT THE TIME SERVICES ARE RENDERED. It is our policy to provide you with a written estimate of fees if you wish, especially for any case where in-hospital or emergency care is necessary. A deposit prior to treatment is required. The balance is due at discharge. I agree, in the event that any amount becomes past due more than 30 days, I will pay interest thereon at 18% per annum (1.5% per month), plus a monthly billing charge of $5.00 from the date the charges were incurred. In the event it becomes necessary to collect fees through the services of an attorney or other collection agency, either prior to or at trial, I agree to pay all reasonable attorney’s fees and/or collection agency fees, and reasonable attorney’s fees incurred. I am the legal owner or the representative of the legal owner of the animal being presented for treatment, and I am over 18 years of age. Notwithstanding anything to the contrary above, if this Agreement is being signed by an Agent of the Authorized Person (for example, a pet sitter or pet transporter), it is agreed and understood that such Agent is NOT responsible for any fees related to the care and treatment of the pet. Only the Authorized Person and/or Co-Owner is responsible for such fees. Consent * I have read and accept the financial policy. Signature * signature keyboard Clear Date * Submit If you are human, leave this field blank.
