New Client Form

Download & Print Form – Client Information Sheet

or fill out the form:

  

Owner's Name:
Birthdate:
Address:
Street, Apt, City, State, Zip
Home#:
Cell#:
Work#:
Marital Status:
Email:
The email is strictly used to notify you regarding information that pertains to you and your pets overall health.
Place of Employment:
Employer's Address:
Employer's Phone#:


Spouse, Nearest Relative or Friend we may contact in case of an emergency:

Name:
Home#:
Cell#:
Relation to Owner:
Address:
Street, Apt, City, State, Zip


Referred By (please select one)

Personal:
(So We May Thank them)
 
Other:


Financial Agreement an Authorization for Treatment

It is our policy to provide you with an estimate of charges for any medical treatment, surgery or hospitalization that will be provided, if requested. A deposit may be required prior to treatment.

Payment Options

At Omaha Animal Medical Group, our mission is to deliver the finest, most cost-effective health care treatment available today. Following the diagnosis, the doctor will advise you of our plan for treatment. Additionally, we will discuss with you the cost of today’s and future treatments. Payment for today’s visit and your future visits are due at the time of treatment. We are sensitive to the fact some people may not be able to pay cash for their treatment(s), therefore, we offer several payment alternatives for your convenience.

  1. Cash or Check
  2. Mastercard, Via, Discover or American Express
  3. Pet Insurance Carrier: Please let us know if you have Pet Insurance or would like more
    information
  4. Care Credit Monthly Payment Plan:
      For amounts from $200 & up
Promotional Period
(Estimated Payoff Period)
    6 Months
Amount Financed     Monthly Payment
$200     $34
$300     $50
$500     $84
$700     $117
$1,000     $167
$2,000     $334
$2,500     $417
$3,000     $500
$5,000     $834

Please indicate below the form of payment that you wish to choose to settle your account.

Cash
Check
Cardtype - Visa, Mastercard, Discover or American Express
Insurance Carrier
Care Credit - Ask for an application at the front desk or apply online at carecredit.com


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