Follow Up Appointment Form Fields marked with an * are required Download The follow-up appointment form is designed to better serve you and your pet(s) during their follow-up exam with his or her veterinarian. Please be as specific as possible regarding any information you provide. Owner Information Owner Information Owner's First Name * Owner's Last Name * Email * Phone Number * Is the person bringing in the pet(s) different than the owner? * Yes No Preferred Doctor (Based on appointment availability) * No Preference Dr. Tim Fleming Dr. Bailey Poling Dr. Ryan Poling Dr. Courtney Dorris How will you be paying for today's visit? * - Select One - Cash Credit Card Scratchpay CareCredit Divider Patient Information Patient Information Pet's Name * How has your pet been doing since last visit? * Please include all information and be as complete as possible. Was your pet prescribed any medications? * Yes No Any specific questions/concerns you would like the doctor to address during your pets visit? * Agreements AUTHORIZATION: ALL FEES ARE DUE AND PAYABLE AT THE TIME SERVICES ARE RENDERED. We accept cash, Visa, Mastercard, Discover, and American Express. In addition, we offer third-party financing through CareCredit and ScratchPay. Please notify a receptionist if you need to apply for third party financing prior to the start of your appointment. Current vaccinations by a licensed veterinarian are required for the admission of your pet to our hospital. This includes admission for elective surgery, boarding, grooming, and well animal care. Proof of vaccinations is required. If the pet is not current on vaccinations at the time of drop-off, client assumes all financial responsibility for bringing the pet up to vaccine standards for Hernando Animal Clinic. Owner administered vaccinations are not acceptable. I agree to allow the doctors and staff of Hernando Animal Clinic to treat my pet and I accept responsibility for all accumulated fees associated with the care that my pet(s) receive. I understand that I am responsible for payment in full prior to discharge according to Hernando Animal Clinic policy and will be held responsible for service or collection fees if balance is not paid in full. I have read and accept the above-mentioned terms and conditions by attaching my full name below as my digital signature. Full Name * Recaptcha If you are a human seeing this field, please leave it empty.