P: 239-263-0480
F: 239-263-0488

10130 Market Street • Naples, FL 34112

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Referral and specialty hospital in Collier County
Animal Specialty Hospital in Naples, Collier County Florida
Compassionate emergency veterinary care for your best friend in Naples FL

New Client Registration Form


You can also download our PDF version and fax it / mail it. Download our new client registration form here

Please make sure you fill out all required fields (*)

Your First & Last Name:

First Name:(*)

Last Name:(*)

Mailing Address:(*)

City:(*)

Zip:(*)

Home Phone:

Cell Phone:

Work Phone:

Email:

Additional Owner:

Emergency Contact:

Emergency Contact Phone:

Employer:

Occupation:

Preferred Method of Contact:(*)

Residential Status:(*)


Name of Pet:(*)

Birthday or Approximate Age(*):

Species:(*)

Sex:(*)

Color:(*)

Breed:(*)

Spayed/Neutered:

Any precautions to be aware of with your pet?

Current on rabies?(*):

Primary Veterinarian’s Name:(*)

Primary Practice Name:


Should my pet become unstable while under ASH’s care and require cardiopulmonary resuscitation (CPR), including cardiac compression, defibrillation, positive pressure respiration, emergency drugs or other heroic interventions, I request or decline such medical intervention as indicated below.
(*)

REQUEST FOR CPR
Having requested such emergency procedures, I understand and agree I am responsible for a minimum resuscitation fee of $500.00 to pay for the services performed while staff members pursue treatment and attempt to reach me for further direction.

DECLINE CPR DO NOT RESUSCITATE MY PET

Thank you for allowing us to care for your pet. In order to provide the highest standard of care for our patients, all fees are due at the time of service. For your convenience, ASH accepts cash, personal check or credit card (Visa, MC, Discover, AMEX & Care Credit). We charge a $40.00 service fee for any returned check. We routinely provide written estimates for all hospitalized patients, and your medical team will discuss that estimate with you prior to admission.

Entering your name here will be your digital signature:

Date

ASH’s marketing manager may want to post photos and/or videos of your pet and his/her progress on ASH’s website and social media platforms, using discretion and your pet’s first name only.
Can we share his/her story if appropriate?(*)

How did you hear about us?:(*)


Payment Policy


To avoid any misunderstanding, kindly read, initial and sign this payment policy before your pet’s treatment. If you have and questions, please contact our staff regarding this policy.

  1. Payment at time of Service: Payment is due in full at the time of services rendered. ASH accepts cash, check, Visa, MasterCard, Discover, and American Express; but we do not offer any payment plans.
    Enter your initails here:
    (*)
  2. Deposits: ASH requires a security deposit of the entire (100%) low-end estimate. The remainder of the invoice is due upon patient discharge.
    Enter your initails here:
    (*)
  3. Estimates: Estimates include items our staff will most likely require to treat and care for your pet during his/her treatment and hospitalization. Please understand the estimate is an approximate only. The final cost may vary from the estimate provided. Our staff will make every effort to inform you of ongoing costs; however, it is your responsibility to ask a staff member for daily updates on your invoice.
    Enter your initails here:
    (*)
  4. Alternative Finance Plans: ASH offers alternative payment options for our clients through Care Credit and Wells Fargo. ASH is in no way affiliated with these programs or these organizations. If you chose to use these plans, the financial relationship is between you and the lender - not ASH.
    Enter your initails here:
    (*)
  5. Pet Insurance: ASH helps initiate necessary forms with your pet-insurance provider; however, ASH is not involved with insurance billing. Your insurance provider will reimburse you directly for your pet’s charges. Clients are responsible for paying the normal deposit (see requirements listed in #2 above) prior to service and paying the bill in full upon discharge, as well as submitting their own pets claim. The insurance company will be responsible for reimbursement to you directly per your pets insurance agreement.
    Enter your initails here:
    (*)
  6. Non-payment of Services: Please know if you do not provide payment in full at the time of discharge, there will be ramifications – including, but not limited to, ASH sending your bill to collections.
    Enter your initails here:
    (*)

I have read and understood the payment policy and consent for treatment at Animal Specialty Hospital of Florida.

The undersigned is presenting their pet for medical services at Animal Specialty Hospital of Florida and voluntarily consents to rendering of such care including diagnostic procedures and medical treatment.

Entering your name here will be your digital signature:(*)

Date(*)


Animal Specialty Hospital of Florida © 2016
10130 Market Street | Naples, FL 34112
P: 239-263-0480
F: 239-263-0488

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