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New Patient / Client Information
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Referral
Pet 1
Name
*
Cat or Dog?
*
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*
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*
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*
Sex (spayed or neutered)?
*
Pet 2
Name
Cat or Dog?
Cat
Dog
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Date of Birth
Sex (spayed or neutered)?
Pet 3
Name
Cat or Dog?
Cat
Dog
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Animal Care Center of Tupelo
5162 Cliff Gookin Blvd
Tupelo, MS 38801
Condition of Admission
Acc Tupelo agrees to receive from the owner of the described animal and to give it such medical, surgical, and dental treatment as it may deem advisable. The owner acknowledges that his/her animal is under the care of his/her personal veterinarian or any other veterinarian designated by the owner(s) of said veterinarian(s). The owners veterinarian or, if said veterinarian is unavailable, any other veterinarian is called as above, the owner acknowledges that the hospital shall not be liable for any acts or omissions in following the order(s) of said veterinarian. The owner hereby authorizes the hospital to release information from the animal’s records to any person, agency, or authority as the hospital in its sole discretion may determine necessary. The hospital shall not be responsible for the loss, theft, or destruction of any personal property left with the animal. The owner or financially responsible party agrees to pay upon discharge ACC Tupelo the charges specified for the care, keeping, and the board of the animal described herewith entrusted to its care. The owner or financially responsible person agrees to pay in full the charges incurred during any period where payment of such charges is pending determination of insurance companies. ACC Tupelo does require payment in full at the time services are rendered. If the pet is ill and requires treatment, an estimate will be provided. If treatment is authorized, there will be a 50%100% down payment required at admission. (Please note that all estimates are subject to a 20% variance.) The owner agrees to move the animal within five days after request for removal is made. If the animal has not been removed within specified time, the owner hereby relinquishes all claims to the animal and ACC Tupelo is at liberty to humanely dispose of the animal as it may see fit. Accounts 30 days delinquent shall bear interest at the maximum legal rate. Should the account be referred to an attorney for collections, the owner or financially responsible party agrees to pay attorney fees, collection cost, and other costs of litigation. Prices are subject to change without notice. The agreement will remain in effect until such time as a different agreement is executed. Any paragraph that shall be deemed to be invalid shall not invalidate the remainder of the agreement. If for any reason transportation has been provided to or from ACC Tupelo by our personnel, neither they nor ACC Tupelo are to be considered liable for loss or injury to your animal. I grant ACC Tupelo, its representatives and employees the right to take photographs of me/ and of my pet, and to copyright use and publish the same in print and/or electronically. I agree that ACC Tupelo who has provided services, along with any billing service and their collection agency or attorney who may work on their behalf to contact me on my phone using prerecorded messages, artificial voice messages, automatic telephone dialing devices or other computer assisted technology, or by electronic mail, text messaging, or by any form of electronic communication.
Thank you for your cooperation and choosing ACC Tupelo for your pets care.
Management
Owner/Agent
*
Date
*
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Day
Year
I consent to all ACC terms and conditions by signing this document electronically.
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Home
Services
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Preventive Care Plans
Dog Training
About
Meet our Team
Pet Education
Forms
New Client/Patient
Boarding Request
Employee Application
Shadow/Volunteer
Contact
Memorial Wall
Home
Services
Veterinary Services
Boarding
Bathing & Grooming
End Of Life Care
Daycare
Spay & Neuter
Preventive Care Plans
Dog Training
About
Meet our Team
Pet Education
Forms
New Client/Patient
Boarding Request
Employee Application
Shadow/Volunteer
Contact
Memorial Wall
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