DMVH Consent to Hospital Policies 01-2025 Primary Owner Name (First & Last Name)* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Address* Home Number Cell Phone Number* Consent* I have read the Terms of Service and Hospital Policies.TERMS OF SERVICE: Our goal is to serve you and your pet in every way possible (we do not offer any form of billing). This includes ensuring your medical team provides the level of care that fits within your budget. It’s important that your financial commitment and responsibilities are made clear before treatment begins. In the case of an emergency, your pet will be stabilized before your medical options are presented. PAYMENT IN FULL is required at the time services are rendered. Feel free to ask for an estimate of charges at any time. If your pet is admitted to the hospital, the veterinarian will ask you to leave a deposit. Moreover, the veterinarian and nurse will provide a treatment plan and estimate for these hospitalized patients. Accepted Forms of Payment: We accept Cash, VISA, MasterCard, American Express, Care Credit and Scratch Pay as forms of payment. We do NOT accept checks. APPOINTMENT CANCELLATION POLICY Unfortunately, like other medical practices, we also have the occasional late arrival or no-show appointment. We do try and manage these as apart from impacting on those who have arrived on time for their appointment; it has a negative impact on the medical team. Often there are cases being treated in hospital and the staff attempts to schedule their day to ensure that they can meet the needs of those patients and scheduled appointments. Arriving late or not showing at all impacts on their ability to manage treatments for these pets. Thus, we do have a few rules and guidelines that the staff work with in terms of late arrivals, cancellations, and no-shows. Late Arrivals: Please be aware that our hospital has a policy wherein if you are more than 15 minutes late for your scheduled appointment time, we will be adjusting our schedule and moving you to the walk in/urgent care service when you arrive. While we certainly understand that delays may happen, we feel we have an obligation and responsibility to do our very best to service clients and patients who are here for their appointments on time. We strongly encourage all our clients to arrive at least 15 minutes early for scheduled appointments, if possible, as we do have administrative paperwork that will need to be completed, especially if you are a new client or have a new pet. No-Shows: When you schedule an appointment and fail to show or call and notify us of your inability to keep this appointment time, it impacts our ability to service clients who may be here already waiting to see a doctor. If you fail to show or call and notify us about difficulty in keeping your appointment time in more than three (3) occasions, you will be prohibited from scheduling an appointment with our medical staff. We will still see your pet, but it will be as a walk in/urgent care arrival only following three subsequent no-shows for appointments. We recognize that your pet may need medical attention and we do not wish to turn your pet away, but you will be subject to any wait times associated with the walk in/urgent care service. CANCELLATIONS: You must cancel an appointment we ask for 24 hours’ notice (during business hours) without being financially responsible for the time. For dental or surgical appointments, we ask for a 48 hours’ notice (during business hours). If the appointment is on Tuesday, the cancellation must be done the previous Friday, during business hours by 11:59 am. The following fees will be applied to your account for not calling as required. Missed Office Visits – No shows & Lat Cancellation Fees: 1st Missed Appointment – Our staff will call to ensure the wellbeing of you and your pet in addition to rescheduling your exam. 2nd Missed Appointment - 50% of the current exam fee will be applied to your account for canceling an appointment a second time with less than a 24 hours’ notice. 3rd & Subsequent Missed Appointment - 100% of the current exam fee will be applied to your account for canceling an appointment a 3rd time and every subsequent time with less than a 24 hours’ notice. For a New Client appointment, or a Saturday appointment, which requires a deposit equal to the physical exam and consultation fee, you must cancel your appointment 24 hours prior (only during regular business hours) to request a refund or keep the credit in case you decide to reschedule your visit. Missed Dental or Surgical Procedures: For a Dental or Surgical procedure – a $250 fee will be applied to your account for canceling an appointment with less than a 48 hours’ notice. If the appointment is on Tuesday, the cancellation must be done the previous Friday, during business hours by 11:59 am. Please Note: 1. A missed appointment fee will need to be paid prior to receiving any new services, prescriptions, or food. 2. Missing three (3) consecutive appointments or frequent cancellations/schedule changes will result in prepayment of your appointment. We thank you in advance for abiding by these policies and helping us keep our clients, staff, and patients on schedule and safe. Please understand that we have created this policy out of respect for those clients who are waiting to have their pets be seen. All information I have provided here is true to the best of my knowledge. By signing below, I acknowledge and agree with the Terms of Service and Del Mar's Hospital Policies. Signature*Date MM slash DD slash YYYY