New Patient Form New Patient Form Name * First Last * Last Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Email * Primary Phone * Secondary Phone Pet's Name * Species (dog, cat, etc.) * Breed * Color/Markings * Age/Date of Birth * Sex * Male Neutered Male Female Spayed Female Does your pet have a microchip identification? * Yes No Does your pet have insurance? If so, who is their provider? * Do you have a second pet? * Yes No How did you hear about us? * Are there any other authorized persons to approve treatment for your pet(s) on your behalf? Round Rock Animal Hospital requires payment in full at the end of your pet's examination and/or at the time of discharge. We accept cash, check (with a valid Texas ID), Visa, MasterCard, American Express, Discover or CareCredit. For new clients dropping off their pet and some treatments or hospitalized care, a deposit may be required. Healthcare plans requiring comprehensive care of $500 or more, will require a 1/2 deposit of the estimated amount to begin your pet's treatment. Round Rock Animal Hospital charges $30 for returned checks. A fee of $20.00 is charged for clients who miss or cancel more than 1 appointment in a calendar year without 24 hours notice. For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier. By typing your name below it serves as your electronic signature and you agree to the foregoing terms of payment. * I have read and accept the financial policy Submit If you are human, leave this field blank.
