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Patient Intake Form

Prior to your appointment at the VSCAN please take a few minutes and fill out the form below. Doing this ahead of time helps our team to be better prepared for your pet's visit and allows your visit to run more smoothly.  

Microchip present
Social Media Consent
Do you have pet insurance?

As a standard part of our intake process we are required to ask what your wishes are regarding CPR services for your pet. In the unlikely event that your pet experiences cardiopulmonary arrest, knowing your wishes ahead of time can greatly improve the chances of a positive outcome. 

Additional fees are associated with CPR services starting at a cost of $500.00

Select an option

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Compounded Medications:

When necessary, The VSCAN may use compounded medications to provide treatment to my pet. Due to the process of compounding medications, the efficacy and formulation are not tested or approved by Health Canada.

I understand that while compounding medication is an accepted veterinary practice by the College of Veterinarians of Ontario (CVO), the use of compounded drugs may pose additional risks.

I understand that my veterinarian will discuss the risks associated with any recommended compounded drug.

I understand that once I provide my consent to any prescribed compounded drugs, my consent is valid until I revoke it or conditions change to the point that all risks and benefits are significantly different.

For more information on the use of compounded drugs, please visit the CVO website.

Please choose one of the options below.

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Privacy Policy:

I consent to the use and storage of my information in accordance with the terms and conditions detailed in The VSCAN Privacy Policy, a copy of which is available at:  www.thevscan.com/privacy-policy

We offer the following methods of payment: Cash / VISA / Mastercard / Debit / E-Transfer

Financial Policy Statement:

 

I understand that full payment must be made for outpatient services at the time services are performed. The doctor will prepare an estimate after examining my pet and I further understand that the estimate is based upon the initial exam of my pet. The estimate may change as further diagnostic and therapeutic procedures dictate. I understand that this is an estimate and the final charges are based on procedures performed. I assume financial responsibility for all charges incurred and agree to pay 50% of the high end of the estimated cost at the time of admission. Additional deposits will be required if further care or procedures are needed, I agree to keep 50% of the total bill on deposit at all times. I further agree to pay the balance of all invoices at the time the pet is discharged from the hospital or when services are otherwise terminated. Final fees may vary considerably from the estimate. I understand that every effort will be made to keep me informed of the current status of my bill throughout my pet's hospitalization. 

I understand that any non-payment will be subject to an interest rate of 2.5% per month and may be submitted to collections in accordance with the Ontario CDSSA guidelines.

I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold Dr. Philip Jull Veterinary Professional Corporation, or any other member of its staff responsible for any errors or omissions that I may have made in the completion of this form. I certify that I am at least 18 years old and proof of age can be verified upon request. 

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