• Welcome! We are eager to meet you and your pets! We are dedicated to the health, happiness, and well being of your pet and treat every patient as if it were our own. We will always take extra care to ensure that your pet is comfortable during its stay in our facility. Please fill out this form, the patient information form (one for each pet), complete the medical history questionnaire, and sign the treatment authorization and payment form. Be sure to attach any previous medical records you have for your pet, and fill out the Medical Records Release Form to have your records transferred to our hospital. Again, we look forward to meeting you and your pet, and we appreciate your visit today
  • CLIENT INFORMATION:

  • Email Address:
  • Email Address:
  • PATIENT INFORMATION:

  • FINANCIAL RESPONSIBILITY

    We accept Cash, Check, MasterCard, Visa, and Care Credit!
  • I understand that payment in full is due at the time that services are rendered. I also understand that South Panola Veterinary Hospital does not extend any line of credit to clients nor offers any payment installation plans. Any offer of financing or financial assistance, and the terms contained therein, is a contract solely between myself and the lending company; furthermore, South Panola Veterinary Hospital will not be responsible for filing claims, negotiating payment settlements, or collecting payment from any financial lending company on my behalf. A copy of the itemized invoice will be provided to me in order to pursue reimbursement from a pet insurance policy; however, the hospital will not be responsible for submitting or collecting insurance claims.

    For my convenience, South Panola Veterinary Hospital accepts cash, personal check (with valid identification), Care Credit, Visa, and MasterCard. Personal checks written on an overdrawn or closed account (bad check) will be sent directly to a Collection Service by the bank. A fee for non-sufficient funds will be added to my balance in such case. Checks may not be post-dated. A service charge will be added to any overdue balance and delinquent accounts will be turned over to a collection agency or justice court for collection.

  • DISCLOSURE and PRIVACY of MEDICAL INFORMATION/USE OF EMAIL

    The patient’s physical or digital medical records are maintained by, and are the property of South Panola Veterinary Hospital, and the information contained therein is the property of the legal pet owner. This protected medical information, including patient history, laboratory findings, diagnoses, and treatments will not be disclosed to anyone outside of the hospital without written consent of the pet owner. Patient information may be provided to a reference laboratory or research laboratory for the purpose of performing diagnostic examinations or testing. Anonymous patient data and medical history may be provided to the state health department and research laboratories for the purpose of collecting and analyzing potential human health threats (zoonoses) and disease prevalence in the pet population. No personally identifying information will accompany records in such cases. Patient’s medical records and history may be released to a veterinary specialist in the case that a referral is deemed necessary for advanced diagnostics and treatments.

    The client (legal pet owner) may request a copy of a patient’s medical records to be released to themselves, another veterinarian, clinic, or hospital by submitting a signed and dated request in writing (medical release form).

    Client’s email addresses are only used by the hospital for the purpose of communicating appointment times, vaccination and recheck reminder, prescription refill reminders, medical results, and collecting client feedback about the services provided by the hospital.

  • THE FORMS ON THIS PAGE, ONCE SIGNED, WILL BE KEPT ON FILE AND WILL REMAIN IN EFFECT UNLESS THERE IS A POLICY CHANGE.

    Thank you


    (If registering more than 2 pets, please submit this form and complete a new form for each pet)