Patient Intake Form

Prior to your appointment at the VSCAN please take a few minutes and fill out the form below. Doing this ahead of time helps our team to be better prepared for your pet's visit and allows your visit to run more smoothly.  

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Microchip Present?
Social Media Consent
Do you have pet insurance?

We offer the following methods of payment: Cash / VISA / Mastercard / Debit / E-Transfer

Financial Consent: I understand that full payment must be made for outpatient services at the time services are performed. The doctor will prepare an estimate after examining my pet and I further understand that the estimate is based upon the initial exam of my pet. The estimate may change as further diagnostic and therapeutic procedures dictate. I understand that this is an estimate and the final charges are based on procedures performed. I assume financial responsibility for all charges incurred and agree to pay 50% of the high end of the estimated coast at the time of admission. Additional deposits will be required if further care or procedures are needed I agree to keep 50% of the total bill on deposit at all times. I further agree to pay the balance of all invoices at the time the pet is discharged from the hospital or when services are otherwise terminated. Final fees may vary considerably from the estimate. I understand that every effort will be made to keep me informed of the current status of my bill throughout my pet's hospitalization. 

I understand that any non-payment will be subject to an interest rate of 2.5% per month and may be submitted to collections in accordance with the Ontario CDSSA guidelines.

I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will hold Dr. Philip Jull Veterinary Professional Corporation, or any other member of its staff responsible for any errors or omissions that I may have made in the completion of this form. I certify that I am at least 18 years old and proof of age can be verified upon request. 

Your Signature

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