Welcome Letter

Thank you for giving East Paulding Animal Hospital the opportunity to care for your pet(s). All items with * must be completed.

Owner Information

Owner First Name(Required)

Owner Last Name(Required)

Co-Owner First Name

Co-Owner Last Name

Co-Owner Employer

Co-Owner Work Phone

Co-Owner Phone

Co-Owner Email

EPAH may text the co-owner above regarding my pets

Yes

Address(Required)

Street Address

Address Line 2

City

State

ZIP Code

Phone(Required)

Email(Required)

EPAH may text me regarding my pets.(Required)

Yes

Pet(s) Information

I consent to EPAH using my pet's image, general and medical information on social media(Required)

Please initial

Pet Name(Required)

Species(Required)

Dog

Cat

Other

Breed(Required)

Color(Required)

Sex(Required)

Male

Neutered Male

Female

Female Spayed

DOB(Required)

Would you like to add a second pet?(Required)

Yes

Second Pet Information

Pet's Name(Required)

Species(Required)

Dog

Cat

Other

Breed(Required)

Color(Required)

Sex(Required)

Male

Neutered Male

Female

Spayed Female

DOB(Required)

Would you like to add a third pet?(Required)

Yes

Third Pet Information

Pet's Name(Required)

Species(Required)

Dog

Cat

Other

Breed(Required)

Color(Required)

Sex(Required)

Male

Neutered Male

Female

Spayed Female

DOB(Required)

Payment Information

Payment is due when services are provided. How will you pay for today's visit?(Required)

Cash

Credit Card

Check

I understand all medical procedures, including vaccinations, have some inherent risk. If you have any questions or concerns about procedures and/or vaccinations, please discuss them with the doctor. Note: We have trained staff to hold your pet during exam or treatment. If you elect to restrain your pet during exam/treatment, please understand we can not be responsible for any injury incurred to you or your pet.(Required)

Please initial.

Signature of Owner(Required)

Date(Required)

EPAH Office Use Only:
Client Number: ______________________ Receptionist: __________________________

Financial Policy

Thank you for choosing East Paulding Animal Hospital. 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. East Paulding Animal Hospital requires payment in full at the end of your pet’s examination and/or treatment at the time of discharge.(Required)

Please Initial.

Payment Options

You can choose from:

Cash, Check, Visa®, Mastercard®, American Express®, or Discover Card®
Convenient Monthly Payment Plans from CareCredit®

Allow you to begin treatment today and pay over time.
Available for any treatment amount.
Can be used repeatedly – for your entire family – without having to reapply.

Deposit

For some treatments and hospitalized care, minimum prepayment amounts are required, ranging from 50% of treatment care plan to $400.00. We charge 1.8% interest or $5.00 (whichever is greater) per month on accounts with outstanding balances older than 30 days. If you have an account 90 days past due, East Paulding Animal Hospital may relinquish your balance owed to an outside collection agency. If needed collection costs and court fees will be added.(Required)

Please initial.

Additionaly Policy Information

East Paulding Animal Hospital charges $30.00 for returned checks.(Required)

Please initial.

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:

Signature Of Owner(Required)

Date(Required)

Signature of Co-Owner

Date

CAPTCHA

Owner Information

Pet(s) Information

Second Pet Information

Third Pet Information

Payment Information

Financial Policy

Payment Options

Deposit

Additionaly Policy Information

Get in touch

770-445-7300

Business Hours

770-445-7300