Appointment Check-In Form - Touhy Animal Hospital

Your Name*
First Last
Pet's Name*
I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute this consent. My signature below certifies that I am over eighteen years of age. I have confirmed my address and contact information to be up to date. I accept that my financial obligations remain at time of services rendered. I have read and understand this authorization and hereby accept and agree to the terms of the consent for treatment.*
Initial here
I agree to pay in full at the time of my appointment. Past due invoices will incur a monthly 5% finance charge. Account more than 60 days past due will be sent to our collections agency.*
Initial here
I understand that any appointment/consultation with a veterinarian will incur an exam fee.*
Initial here
I understand that I cannot return dispensed medication after payment has been processed and I have left the premises.*
Initial here
I understand that Touhy Animal Hospital will not authorize any prescription refills through email, phone or fax for 3rd party online pharmacies (such as Chewy, PetMeds, etc.). Please request a written script at the time of your visit. I take full responsibility for products purchased on those platforms.*
Initial here
I agree to act in a courteous manner to all Touhy Animal Hospital personnel.*
Initial here
I consent for Touhy Animal Hospital to take pictures of my pet to use on social media platforms.*
- Yes
- No
Best phone number to reach you at today:*
Please note:
Cancellations made with less than a 24 hour notice significantly limits our ability to make the appointment available for another patient in need. Appointment cancellations with less than 24 hours notice will incur a $42.00 charge. Grooming appointments with less than 48 hours notice will incur a $42.00 charge. Surgery/Specialist appointments with less than 48 hours notice will forfeit their deposit.
Please allow 24 hours for all medication refills and food order requests
Don't forget about our 50% off Vaccine Day every Thursday! (only valid on rabies, distemper, and bordetella vaccines)
Save $$$ and enroll in our loyalty program, download the Pet Desk app and opt in to start earning discounts on services!
Signature*
Date*
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