Please note: all new client forms must be submitted prior to scheduling a new client appointment Owner’s Name* First Last Secondary Owner's Name First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Cell Phone*Work/Other Phone*Secondary Owner's PhoneEmail* Drivers License/ID* Emergency Contact Name* Emergency Contact Phone Number*How did you hear of us?* Drove By Facebook Google Internet Search Website Other Pet (Patient) InformationPet’s Name* Date of Birth* Species* Dog Cat Other Sex* Male Male - Neutered Female Female - Spayed Breed* Color* Financial Responsibility and Policies* I hereby authorize the veterinarian to examine, prescribe for, or treat the above-described pet(s). By signing this form, I agree I am 18 years or older and I assume full responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit maybe required for surgical treatment. Financial Policy Thank you for choosing Southwoods Animal Hospital. Our mission is to partner with our clients, staff, and community to help pets live longer, happier, and healthier lives. 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. Southwoods Animal Hospital requires payment in full at the end of your pet’s examination and/or at the time of discharge. We do not provide in-hospital payment plans. Payment options include Cash, Check, Visa, Mastercard, Discover, and American Express. If you would like to use a third-party monthly payment merchant, we work with Care Credit and Scratch Pay. **All services and procedures performed within the hospital are non-refundable** Outstanding account balances past 30 days will be sent to a collection agency. The client will be financially liable for all fees associated with the collection process including but not limited to attorney fees incurred during collection efforts. Additional Policy Information Southwoods Animal Hospital charges $25.00 for returned checks and client accounts are subject to management review for continued services. Pet Insurance:For clients with pet insurance (non-Trupanion), we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier. If you have Trupanion insurance, please see one of our team members about Express Payment Options. Social Media Policy* I understand that by signing this document, I authorize the staff at Southwoods Animal Hospital to use photos of my pet on their social media, website, and advertising. I have read and understand my Client Rights & Responsibilities (linked below) Southwoods Client Care Agreement. By signing below, you agree to the foregoing terms of payment and policies.CAPTCHASignature* Δ
