New Client Form


Please fill in the form below.
 

Full Name
Address
Phone Number
Pet Information

I, being responsible for the described animal, have the authority to grant my consent to receive, prescribe and treat my pet. Further, I accept full financial responsibility for authorized medical treatments. I also authorize Advanced Animal Care to fax my animal's records to my regular veterinarian

Authorization

Client Agreement: I understand that AAC utilizes the services provided by the Madison County Attorney for returned checks and all accounts sent to the county attorney are subject to additional fees and penalties. I also understand any balance that remains unpaid for any reason will be sent to a professional collection agency and I agree that I will be responsible for additional fees and penalties incurred to Advanced Animal Care for collections on this account, as well as interest accrued at 1.5% monthly (18% annum). Advanced Animal Care reserves the right to present past due accounts to small claims court in place of a collection service. I have read the above and understand the hospital payment policy. I acknowledge that I am the responsible owner of the pet(s), or authorized agent of the owner, associated with the below named pet(s) and represent all other owners. I assume responsibility for all charges incurred in the care of the animal. You must be 18 years or older to legally sign this consent. All fees are due at the time services are rendered. AAC does not offer payment plans, but clients may apply for Care Credit.

AUTHORIZATION FOR RELEASE OF RECORDS

Under Kentucky law, we must have a release signed by you before any information regarding your pets can be released to others.

Please indicate below if you have anyone that you know will need information regarding vaccination history, pet's health status, etc. Please note if your pet is hospitalized only people listed in this form can call and check on the animal.

PLEASE NOTE, only the OWNER and CO-OWNER is authorized to make decisions regarding the health care of your pet.

I have verified that all information above is true