New Patients Form Check One Mr. & Mrs. Mr. Mrs. Ms. Miss Dr. Rev Name First Last Email Best Phone # to reach youEmergency contact/phone number2nd NumberOther Authorized Person(s)Mailing Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physical Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred method of contact Phone Call Text Email Other If OtherHow did you hear about us? (Facebook, Website, newspaper, Friend, Other)About the PetPet NameDog, Cat, OtherBreedColorBirth Date/AgeSex Male Female Neutered Spayed Is your pet microchipped? Yes No Are your pet's vaccines current? Yes No If so, where were they done?Did you bring your pets records or have them faxed? Yes No Third Choice May we call for records? Yes No May we call for records? Yes No SignatureMay we use your Pet(s) picture on our social media? Yes No Pet 2Pet NameDog, Cat, OtherBreedBirth Date/AgeSex Male Female Neutered Spayed Is your pet microchipped? Yes No Are your pet's vaccines current? Yes No If so, where were they done?Did you bring your pets records or have them faxed? Yes No Third Choice May we call for records? Yes No If so, where?Pet 3Pet NameDog, Cat, OtherBreedBirth Date/AgeSex Male Female Neutered Spayed Is your pet microchipped? Yes No Are your pet's vaccines current? Yes No If so, where were they done?Did you bring your pets records or have them faxed? Yes No Third Choice May we call for records? Yes No If so, where?Financial PolicyThank you for choosing the Animal Medical Center of Lehigh Acres. Our primary mission is to deliver the best and most comprehensive veterinary care available for your pet. An important part of the mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options. The Animal Medical Center of Lehigh Acres requires payment in full at the end of your pet's examination and/or at the time of discharge.While your pet is boarding with us during storm season, fireworks and our construction, if your pet is showing signs of anxiety, we will speak with a doctor on their behalf and if prescribing an anti-anxiety medication is in the best interest of your pet, we will dispense what the doctor recommends, and this medication will be reflected in the cost of your invoice.Payment Options: You can choose from: -Cash, Check, Visa, Mastercard, Discover or AMEX -Convenient Monthly Payment Plans* from CareCreditCareCredit® Patient Payment Plans • Allow you to begin treatment today and pay over time • Available for any treatment amount • Can be used repeated ly- without having to reapply*For some treatments or hospitalized care, a deposit is required. Healthcare plan requiring comprehensive care of more than $500 or more, will require a 25-50% deposit to begin your pet's treatment.Additional Policy Information: The Animal Medical Center of Lehigh Acres charges $25 for returned checks. For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier.If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your pet.By signing below, you agree to the foregoing terms of payment:/SignaturePhoneThis field is for validation purposes and should be left unchanged.Like Us On FacebookAppointmentsWe will do our best to accommodate your busy schedule. Please schedule an appointment today!Request AppointmentGet Directions
