Text Client-Patient Registration Form Owner's NameSpouse/otherAddressCityZipcodeHome PhoneSpouse's Work PhoneDriver’s LicenseE-mail Address Financial PolicyThank you for choosing Gateway Animal Care Group, PC. Our primary mission is to deliver the best and most comprehensive veterinary care available for your pets. An important part of the mission is making the payment for optimal care as easy and manageable for our clients. We do require payment in full for services rendered, however we offer several payment options.Payment Options-Cash, Check, Visa, Mastercard, American Express, Discover Card, and Care CreditDeposit & BillingFor some treatments or hospitalized care, a deposit may be required. For health care plans requiring comprehensive care of more that $300, we will require a 50% deposit to begin your pet’s treatment. Gateway Animal Care Group, PC may relinquish your balance owed after 90 days to a collection agency.* If you have a returned check it will be transferred toPay Tek Solutions, which will then electronically retrieve the funds andtheir collection fee of ($39.00). We reserve the right to refuse to accept checks for anyone who has returned a check in the past. *If in the event this account is referred to a collection agency, the client agrees to pay to Gateway Animal Care Group, P.C. all cost of collection including attorney fees, collection fees and contingent fees to collection agencies of not less than 35 percent, such contingency fees to be added and collected by the collection agency immediately upon default and our referral of this account to said collection agency. *Also, you agree, in order for us to service our account, we may contact you by telephone at any number provided by you, including wireless telephone numbers; e-mail or text message. This includes use of pre-recorded messages and /or use of an automated dialing device. * Additional Policy InformationFor clients with pet insurance, we do require payment when services are rendered. However, we are happy to provide you with the necessary documentation so that you may submit your claim to your carrier. **Signature for Release of RecordsI, ______________________________________________ give permission for my pets medical records to be released to requesting sources (i.e., spouse, groomers, pharmacy, veterinarians, etc.) by phone, fax, email. **We cannot release medical records without signed consent. If not signed, you would need to come to our office in person with identification and pick up your records and deliver them to requesting sources. Signature of Owner and Responsible PartyDate Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.