Client Consent Form

We respect your privacy and only use your email address for the following reasons: to provide you with diagnostic test results for you to maintain with your pet’s health records, to provide you access to your pets’ records online through Petly, to provide you access to our online store and features of our Centerville Animal Hospital App, to send environmentally friendly e-service reminders, to communicate time-sensitive alerts and to provide valuable savings from our trusted partners.

How would you like us to notify you of future service reminders? (Check all that apply).
Would you like to maintain a credit card number on file for convenience or in case of emergency?

We pledge to do our very best to care for the total health needs of your pets. In return we ask you to accept the responsibility for charges incurred in the treatment of your pet and understand that payment is due when services are rendered. Please feel free to ask for an estimate prior to any services.

We accept cash, check (with a photo ID), VISA, Mastercard, Discover, American Express and Care Credit. We offer payment plans including: Care Credit, iCare Financial, Payment Banc and Scratchpay for veterinary services only (eligibility requirements apply). You must notify a staff member or the doctor in advance of receiving services that you intend to apply for a payment plan. We will be happy to guide you through that process.

Co-Owners and Authorized Decision Makers- This is very valuable. We cannot disclose information or proceed with services including medical treatment unless we have consent from the individual listed on this client consent form. For families or married pet owners all decision makers should be listed.

A co-owner is equally responsible for the care and cost of your pets. Would you like to designate a coowner?
Is the Co-Owner's address the same as the address listed above?
An authorized decision maker is an emergency contact person empowered to make medical decisions for your pet if we are unable to reach you. You are responsible for the cost of any authorized services. Would you like to designate an authorized decision maker?

Payment is due at the time services are rendered. When payments is not made or is in default, additional collection fees, legal fees, and court costs may be charged if your past-due account must be referred for collection.

We love our patients and want the world to know! May we have your permission to use photographs or other audiovisual materials taken of you or your pet(s) for promotional printed material, our website, and social media?

I hereby authorize this hospital to receive, prescribe for, treat or perform surgery upon my pet(s). I have read and understand the terms on this form. (You will be asked to sign this electronically once you arrive at the practice)

Thank you in advance for completing this entire form and for understanding that the more information we have, the better it is for your pet. The information is updated yearly and it allows us to communicate with you and those you appoint, not just during the context of this appointment but as unforeseen circumstances arise throughout the year. We promise, if we didn’t need the information, we wouldn’t be asking for it.

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