Refill Request | Shannon Animal Hospital

Please fill out one form per pet.

Your Name (First) *

Your Name (Last) *

Email *

Phone Number *

Secondary Phone Number

Address *

City *

Zip *

Preferred Contact Method

Call

Text

Place of Employment *

Alternative Contact Name *

Alternative Contact Number *

Pet(s) Name *

Date & Time of Pets Appointment *

Pet Species

Pet Breed *

Sex *

Fixed *

Color *

Birthday *

Microchipped?

Yes

Does your pet have any allergies? If yes, please list.

Is your pet currently taking any medication? If yes, please list.

Previous Vet Clinic

Who can we thank for referring you?

Do you give us permission to take photos of your pet and post on social media? *

Yes

If yes, can we use them on our social media sites? *

Yes

Does your pet(s) have insurance? If yes, please list the policy number

Available Discounts

Military

Senior Citizen (60+)

We are frequently asked about the prices of our services. Charges vary based on the type of care needed by your pet. Please ask for specifics when discussing treatment recommendations with your pet’s doctor. While our hospital does not offer in-house payment plans, we do accept all forms of payments. All charges are due at the time of service. We accept Care Credit for transactions over $200.

I am the owner (or authorized agent for the owner) of the pet named above and authorize Snohomish Station Animal Hospital (“SSAH”), its veterinarians, technicians, and assistants to perform services, procedures, diagnostics, vaccinations, treatments, and/or administration of medications as deemed necessary or advisable in connection with or relating to the matters described in the attached estimate or the matters that have otherwise been explained by the SSAH veterinarian or other employee. I understand there is a risk of complications with every procedure, including the possibility of death as a severe complication of surgery, anesthesia, or other procedures. I also understand that there is no guarantee as to the results of any procedures, diagnostics, vaccinations, or treatments. I understand that I may ask questions regarding any procedure, diagnostic, vaccination, or treatment recommended by the SSAH veterinarian before it is performed. I understand that a veterinarian may not be present at the hospital at certain times and that veterinary technicians or assistants may perform certain functions in the preparation and care of my pet even when a veterinarian is not present. I also understand that no staff will be present in the hospital overnight. Unless the veterinarian advised that my pet may remain unattended in the hospital overnight, I will need to take my pet home or transfer my pet to a hospital offering overnight care at the end of the day. If I fail to pick up my pet before the hospital closes for the day, SSAH may transfer my pet to a hospital offering overnight care if the veterinarian determines that my pet cannot be left unattended overnight. I understand and agree that I am responsible for the payment of any charges for such overnight care. I agree that hospital staff may walk my pet outside. I understand in the event of an emergency, it may be necessary for my pet to be taken to an emergency hospital. I authorize SSAH and its veterinarians and other personnel to transport my pet to an emergency hospital and to obtain treatment by the emergency hospital to stabilize my pet if I cannot be reached. SSAH and its personnel may disclose such information and records regarding my pet to the other hospital as they consider necessary. If I neglect to pick up my pet within 7 days, SSAH may assume that my pet has been abandoned and is authorized to make such arrangements as it may deem best. I understand that payment is due, in full at the time services are rendered. If for any reason payment is not made at the time services are rendered or within 7 days thereafter, I understand that my account may be referred to a collection agency. In the event that my account is referred to a collection agency, I agree that SSAH may add an amount to my outstanding account balance to reimburse SSAH for the reasonable collection charge (but not including attorney’s fees) imposed by the collection agency.

I understand that SSAH does not accept personal checks for payment unless prior arrangements are made. I understand that Care Credit is accepted but must be a transaction of $200 or greater and that 6 months deferred interest is the only option SSAH offers. Per Care Credit regulations the cardholder must be present with the Care Credit account information and two forms of ID to be used as payment.

I give consent for my pet to be scanned for a microchip. If a microchip is found I understand and consent for the registered microchip owner to be contacted. Additionally, I understand that if my pet’s microchip is registered to another owner that they are the legal owner and I agree to turn the pet over to them or for the pet to be held by SSAH until the registered owner can obtain the pet.

I agree that myself and any authorized agent that represents me will treat all staff members and other clients with respect at all times. I understand that SSAH has zero-tolerance for swearing, yelling, or disrespectful speech toward any staff member or other clients. Behavior as such can result in termination of care. All staff members are empowered to report any and all abuse from clients.

I agree to keep my pet on a leash or in a carrier at all times while in the lobby for the patient and human safety.

I agree to inform the staff if my pet has ever been aggressive, bitten anyone or required a muzzle or extra restraint in any past circumstances, veterinary related or otherwise.

I understand that SSAH offers Ultimate Care Plans. If I do not elect to enroll today, future coverage will not be retroactively applied. I understand that not all pets are eligible to be enrolled in an Ultimate Care Plan and that this is at the discretion of SSAH and it’s staff.

I authorize SSAH to share my pet’s medical records with facilities when requested by a third party, such as a veterinary clinic, groomer, boarding facility, training, daycare, insurance, etc.

If I miss more than 2 appointments and/or cancel less than 24 hours prior to 2 appointments a deposit will be required to schedule any future visits. The deposit is $78 and can be used toward the visit, however, if I do not keep my appointment that deposit will be non-refundable.

I understand that WA State WAC 246-100-197 requires all dogs, cats and ferrets be current on their Rabies vaccination. I understand that SSAH supports this law and requires all patients healthy enough to receive vaccinations to be current on their Rabies vaccination in order to continue to receive veterinary care at SSAH. If you do not wish to vaccinate a Rabies titer will be required annually, at your cost.

I understand that WA state WAC 246-933-200 requires veterinarians to have examined the animal within the past year or sooner if medically appropriate, dependent upon the need as deemed by the veterinarian, in order to prescribe any medication. This rule applies to the prescribing of prescription flea/heartworm/intestinal parasite preventatives, along with all other FDA regulated drugs.

Checking this box confirms my electronic signature.

Monday	8:30AM to 12:00PM	2:00PM to 6:00PM
Tuesday	8:30AM to 12:00PM	2:00PM to 6:00PM
Wednesday	8:30AM to 12:00PM	2:00PM to 6:00PM
Thursday	8:30AM to 12:00PM	2:00PM to 6:00PM
Friday	8:30AM to 12:00PM	2:00PM to 6:00PM
Saturday	8:30AM	12:00PM
Sunday	CLOSED	CLOSED

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