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Pre - Exam Questionnaire

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  • 2
    Please Select
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    • Indoor
    • Outdoor Supervised
    • Outdoor Unsupervised
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    We occasionally prescribe controlled substances and must have a humans date of birth on file for our feline patients.
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    • Yes
    • No
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    Please make sure to complete this section before moving forward with the form.
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  • 30
    Please Select
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    • Yes
    • No
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  • 31

    PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE RENDERED

    In admitting/presenting my pet(s) for diagnostics, treatment, surgery, I authorize the doctors of Arlington Cat Clinic, LTD and their support staff, to administer such treatment and/or perform such diagnostic or surgical procedures as deemed necessary. It is understood that an estimate of charges will be given for hospitalization and surgeries. No guarantee or assurance can be made as to the results that may be obtained. Further, I realize that these charges may exceed a given estimate if complications arise. I understand that I will be contacted prior to treatment if possible. I agree to pay the Arlington Cat Clinic, LTD at the time services are rendered. If the account goes delinquent; no payment in 30 days, the account will be assessed a 2.00% billing fee on the outstanding balance(24% yearly). I further agree if the account is transferred to collections, I will be responsible for all costs necessary to collect this balance including collection fees, attorney fees, court costs, and filing fees. If a check is returned non-sufficient funds, a minimum charge of $25.00 will be added to the amount owed.

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  • 32
    This appointment is set just for your pet. Because appointments are valuable to our pets and clients, we do respectfully ask for 24 hour notice for cancellations. Repeated rescheduled appointments, cancellations, or no-shows, will be assessed a fee. We appreciate your courtesy and understanding.
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