Name *

First

Last

Street Address *

Address Line 1

City

State

Zip Code

Mailing Address

Address Line 1

City

State

Zip Code

Home Phone *

Work Phone

Cell

Layout

Drivers License

State

Email Address *

Layout

Employer

Phone

Address

Address Line 1

City

State

Zip Code

Other Responsible Party

Name *

First

Last

Street Address *

Address Line 1

City

State

Zip Code

Home Phone *

Work Phone

Cell

Layout

Drivers License

State

Layout

Employer

Phone

Address

Address Line 1

City

State

Zip Code

Emergency Contact

(Not the same as above)

Name *

First

Last

Layout

Phone

Relationship

Professional fees are due when services are rendered. We accept cash, checks, VISA, MasterCard, Discover, and Care Credit. I understand that I assume responsibility for all charges, past and present, incurred in the care of my animal(s), and they will be paid at the time of release. I also understand that a deposit may be required for surgical treatment or hospitalization. I realize that if my account is not paid in full, it will be charged interest at the rate of 18% annually ($0.50 min). Accounts sent to collections will be subject to a minimum fee of 30.00. There is a return check fee of $35. *

I have read and accept

Signature *

Date *

Pet's Name *

Species (dog, cat, etc.) *

Age/Date of Birth *

Breed *

Policies

Please read through our current hospital policies and initial

Photograph *

I agree Parkway Animal Hospital may take pictures and videos of my pet for continuing education, medical publications, promotion, social media, etc. These images will have no identifying information about me or my family associated with them. They may contain my pet's name. I will claim no ownership of or authority over said images.

No Shows & Late Cancellation Fees *

I understand that Parkway Animal hospital requires a 24-hour advanced notice for changes in your scheduled exam. With the 1st missed appointment, our staff will call to ensure the well-being of you and your pet, in addition to rescheduling your exam. Additional missed exams and late cancellations may result in a $50.00 fee or upfront payment of exam fees.

Emergency and After Hours *

Parkway Animal Hospital provides consultation and or care for our current clients. If we have not seen the patient or your family has not visited the clinic within the last 3 years, an emergency client reinstatement fee will apply.

Mutual Respect *

Our team is committed to treating all clients with dignity and respect. We do ask that you give our team the same consideration. For the safety and well-being of the patients in our care, other clients, and our team, we will not tolerate cursing, yelling and/or any attack on our staff. Failure to act in a calm and respectful manner may result in the termination of your relationship with Parkway Animal Hospital.

How did you hear about us?

Other

Online Forms

New Client Form

Other Responsible Party

Emergency Contact

Policies

Ready to Visit Us?

Location

Contact Information

Hours

What Can We Do to Care for Your Pet?