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