PAH HOME
OUTSIDE/ONLINE PHARMACY POLICY
CANCELLATION NO SHOW POLICY
PAH Client Resources
Our Doctors
>
Dr. Teri Leichner DVM, MS, DACVIM-LA (Practice Owner)
Dr. Beverly Basham DVM
Dr. Marianne Martin DVM CVA
PET HEALTH
Services
Microchip Your Pet
Nutritional Counseling
Spay & Neuter
Vaccinations
Wellness Care
X-Rays
Ultrasound
Acupuncture
Chinese Herbal Therapy
Laser Therapy
Dentistry
Surgery
PAH Personal Payment Plans
Contact PAH
Contact PAH
Request Appt
Request Refill
Outside Professional Records Request
New Client Registration Form
Welcome! Thank you for choosing Pioneer Animal Hospital for your pet's needs. Please complete this form in entirety.
Client (PetOwner) Name
*
First Name
Last Name
E-mail
*
example@example.com
Main Contact Number -Cell Preferred
*
Secondary Contact Number
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How Would You Prefer To Be Contacted Regarding Your Pet's Health Care?
*
Cell Phone (Main Number)
Text (Main Number)
Email
Other
Is There a Spouse/Partner/Family Member Who Should Be Listed On Your Account?
Yes
No
Spouse/Partner/Family Member Name
First Name
Last Name
Please tell us how the above person is related to you so we can refer to your relationship appropriately.
Spouse/Partner/ Family Member Contact Number:
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IN CASE OF EMERGENCY Is there anyone else (besides above listed contacts) who should be listed on your account, who has ongoing permission to make medical decisions for your pet(s)?
Yes
No
Emergency Contact:
First Name
Last Name
Relationship
Contact Number
Additional Account Name
First Name
Last Name
Relationship
Contact Number
How did you hear about us?
*
Google (or other search engine)
Facebook
Instagram
Nextdoor.com
Yelp
Saw our hospital (location)
Humane Society
A PAH Team Member
Is there someone we can personally thank for your referral?
Please tell us who we may thank for your referral!
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PAH Client Policies and Procedures
I agree to keep my pet safe and secure. Dogs will be kept on leash or in a portable crate/carrier. Cats will be kept in portable crate/carriers while on the premises of Pioneer Animal Hospital.
*
Initial
We Love Social Media! Do we have your permission to post pictures of your pet(s), you and your pet(s) and/or your pet(s) and our team on Facebook, Instagram, www.pahcares.com and any other print marketing and/or other social media outlets we may choose to use?
*
Yes
No
Pioneer Animal Hospital provides reminders for appointments or services due by email, text and our hospital app Vitus Vet. If you choose not to be contacted by email, text and/or our hospital app, we cannot guarantee timely reminders regarding your pet(s) health. In addition, if you unsubscribe from PAH electronic communications or revoke permission to contact you digitally, we will be unable to provide you with timely information regarding your pet's health. Please initial below indicating that you understand the above.
Initial
Pioneer Animal Hospital uses email, text and our own hospital app Vitus Vet for communications regarding our patient's reminders for health care needs. Do we have your permission to contact you via email, text and/or our app regarding these reminders?
*
Yes
No
I agree to release Pioneer Animal Hospital from all claims for libel, slander, invasion of privacy, infringement and copyright or right of publicity or any other claim and confirm that you are over the age of 18 years old. (initial below)
*
Initial
Our office accepts Visa, Mastercard, Discover, and American Express, Apple Pay and most other major credit and debit cards. In addition, we also offer 3rd party financing options for our clients via Care Credit. We accept a variety of Care Credit plans based on the total transaction amount for your pet. Care Credit requires that payment only be made for services as they are rendered, we cannot charge services to your account in advance. Additionally, use of Care Credit requires that the card be present every time and that two forms of identification are verified. We appreciate your understanding of our desire to protect your account/identity. We also provide access to PAH|VB Personal Payment Plans. Full payment is due at the time of service. This includes any charges/fees agreed to by my authorized proxy. Our team is happy to provide any client with a written treatment plan prior to services being rendered. Client will be responsible for a 2% monthly finance charge on accounts over 30 days and any collection and/or legal fees on accounts over 90 days. Your initial below indicates your agreement with these policies.
*
Initial
Our goal is to provide timely care to all our patients and to respect not only the client and veterinarian’s time, but the constraints of a tightly booked schedule. If you must cancel your appointment, we request a text, call or email as defined below. This allows us to accommodate other patients who may need prompt medical care. NEW CLIENTS a. Appointment must be cancelled at least 24 hours prior to the scheduled appointment time. Cancellations that occur with less than 24 hours’ notice will result in a $71.00 charge. “No Show’ appointments will also be charged a $71.00 fee. b. In the event the client arrives late to their appointment, they will be required to pay “non-refundable scheduling fee” equivalent to the estimated appointment if they would like to reschedule. Should this happen at the next appointment, the client forfeits their right to any future bookings. c. If one (1) no show occurs, the client will be required to pre-pay a “non-refundable scheduling fee” equivalent to the estimated appointment being scheduled for. If that scheduled appointment is attended successfully as scheduled, the fee will be applied to the appointment. If two (2) no shows occur, the client forfeits their right to any future appointment bookings.
*
Initial
I acknowledge that I have read and understand all of the above. Signature
*
Clear
Submit Form
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PAH HOME
OUTSIDE/ONLINE PHARMACY POLICY
CANCELLATION NO SHOW POLICY
PAH Client Resources
Our Doctors
>
Dr. Teri Leichner DVM, MS, DACVIM-LA (Practice Owner)
Dr. Beverly Basham DVM
Dr. Marianne Martin DVM CVA
PET HEALTH
Services
Microchip Your Pet
Nutritional Counseling
Spay & Neuter
Vaccinations
Wellness Care
X-Rays
Ultrasound
Acupuncture
Chinese Herbal Therapy
Laser Therapy
Dentistry
Surgery
PAH Personal Payment Plans
Contact PAH
Contact PAH
Request Appt
Request Refill
Outside Professional Records Request