CLIENT INFORMATION FORM. In order to accurately submit claims for services to your insurance company it is essential that you present a current insurance identification card and the client information form must be filled out completely and accurately. Any omission of necessary information will result in your being responsible for the charges for services you receive. In addition, you are solely responsible for notifying the office PRIOR to your scheduled appointment with any changes in your insurance coverage and/or will be responsible for immediate payment on any service that is denied or not covered by your insurance company including, but not limited to all deductibles, co-insurances, and co-payments. I have read and understand the above statement. Client Signature: Date: Parent Signature: Date:
CLIENT INFORMATION FORM. This agreement, dated is made between VetMedics Inc. located at 000 Xxxxxxxxxx Xx. Xxxxxxxx, XX.00000, referred to as “VetMedics” and the Client. Please fill out the following: Owner’s Last Name: First Name: Street: Apt#: City, State: Zip: Home Phone: Emergency Phone:___________________________ Work Phone: Email:______________________________________________________________________________________________ PET INFORMATION: Pet Name: _______________________________ Species: _______________________ Age: ___________ Breed: _______________________ Sex: M / F Neutered: Y / N Color: _________ Weight__________ PRICING: CASH DISOVER: _____ AMEX______ VISA: MC: ______ Credit Card #:__________________________________________________ Security Code:______________ Expiration Date:_______________________________ Billing Zip Code: __________________ PLEASE NOTE: PERSONAL CHECKS ARE NOT ACCEPTED AND PAYMENT IS DUE WHEN SERVICED ARE RENDERED. A CREDIT CARD IS REQUIRED FOR REQUEST OF EMERGENCY SERVICES AND A DEPOSIT OF NO LESS THAN $175 WILL BE MADE. VETMEDICS RESERVES THE RIGHT TO CHARGE SAID CREDIT CARD AT COMPLETION OF SERVICE. PLEASE NOTE, PRICE GIVEN MAY VARY DEPENDING ON SERVICES NEEDED AND IS AN ESTIMATE ONLY. ( ex: additional oxygen, medications, etc ) . OWNER HAS 15 MINUTES FROM REQUEST OF DISPATCH TO CANCEL. CANCELLATION OUTSIDE OF 15 MINUTES WILL INCUR A $175 FEE. CLIENT SIGNATURE: __________________________________________________________________________ Non-Emergency Transport [ ] ONE WAY TRANSPORT SINGLE TEAM MEMBER UP TO 25 MILES $ 95.00 + TX [ ] RETURN TRANSPORT SINGLE TEAM MEMBER $ 40.00 +TX [ ] WAIT FEE PER HALF HOUR $ 25.00 + TX Emergency Transport [ ] ONE WAY TRANSPORT UP TO 25 MILE RADIUS SINGLE TEAM MEMBER $ 195 [ ] ONE WAY TRANSPORT OVER 25 MILE RADIUS SINGLE TEAM MEMBER $295 + (dependent on distance ) [ ] ADDITIONAL TEAM MEMBER $ 130.00 [ ] WAIT FEE PER HALF HOUR PER TEAM MEMBER $40.00 ***PLEASE NOTE THAT MILEAGE IS CALCULATED FROM LOCATION OF VETMEDICS IN FISHKILL, NY Additional Services [ ] OXYGEN PER HALF HOUR $65.00 [ ] INFUSION PUMP FOR IV FLUID THERAPY $85.00 [ ] MEDICATION ADMINISTRATION $25.00 [ ] WOUND DRESSING/ CLEANING $45.00 [ ] CPR $200.00 *** YOU HERBY THE CLIENT AUTHORIZE CPR IF NECESSARY: YES:_____ NO:_____ CLIENT SIGNATURE:___________________________________________________ Home LVT Visit* **PLEASE NOTE ALL TREATMENTS/MEDICATIONS HAVE BEEN AUTHORIZED BY PATIENT/OWNERS VETERINARIAN. VETMEDICS DOES NOT DIAGNOSE ANY ILLNESS OR PRESC...
CLIENT INFORMATION FORM. The Community Team uses a common registration form and a common format for development of an Education and Employment Action Plan to use with each young person. This Plan identifies the steps required to meet goals, and the agencies/people who can assist at each stage. School Transition Managers and Jobs Pathway staff will undertake much of the assessment work. Community agencies use the form with their clients if employment and education goals were necessary. Employment placement agencies use it with a young person where it is appropriate. The information form may identify issues which the young person needs to address before an education/employment placement is secured, or which require ongoing support. Any referral for these purposes would be confidential and would meet the privacy principles outlined in the Spirit of Agreement.
CLIENT INFORMATION FORM. In order to accurately submit claims for services to your insurance company it is essential that you present a current insurance identification card and the client information form must be filled out completely and accurately. Any omission of necessary information will result in your being responsible for the charges for services you receive. In addition, you are solely responsible for notifying the office PRIOR to your scheduled appointment with any changes in your insurance coverage and/or will be responsible for immediate payment on any service that is denied or not covered by your insurance company including, but not limited to all deductibles, co-insurances, and co-payments. I have read and understand the above statement. Client Signature: _______________________________________________________________________________ Date: _______________________________________ Parent Signature: _______________________________________________________________________________ Date: _______________________________________
