Printable PDFNew Patient Information FormPlease fill out and submit this form prior to your visit.Client InformationName* First Middle Last Address* Street Address City State / Province / Region ZIP / Postal Code Primary Phone*Secondary Phone (if applicable)Email* Preferred Method of Contact* Phone EmailPatient InformationPatient's Name*Dog or Cat?* Dog CatBreed*Age*Sex*Color*Current MedicationsCurrent FoodPrimary Care VeterinarianPoliciesBy checking these boxes, you agree to the following:Policies* Treatment Authorization - I hereby authorize Mid-Michigan Veterinary Cardiology to perform medical and initial diagnostic procedures on my pet as required for diagnosis and treatment. I understand that I can terminate treatment at any time.Policies* Payment Agreement - Full payment is due when services are rendered. Payment may be by cash, personal in state check (with proper identification), Care Credit, or accepted credit cards. Any checks returned for “insufficient funds” will be assessed a $35.00 processing fee, and any overdue balances shall be subject to interest at the rate of eighteen (18%) percent per annum. I also agree to pay for any and all costs of collection, including costs and reasonable attorney’s fees incurred by Mid-Michigan Veterinary Cardiology. To avoid misunderstandings, please let us know immediately if these terms are not satisfactory.Statement of UnderstandingI understand that I, as the owner or agent, am financially responsible to Mid-Michigan Veterinary Cardiology for all charges relating to this patient. I have read and agree to the treatment authorization. I also accept the financial obligations.Signature*Date* MM slash DD slash YYYY
