Hanna's Teddy Hospital Admitting Form

Toll Free: 877-7BEARMD (877-723-2763) Local: 717-626-1180

Fax: 717-626-3155

Email Dr. Hanna: teddydoctor@hannabrucebears.com

Email Nurse Nancy: teddynurse@hannabrucebears.com

Office Hours: Tues - Friday Closed: Saturday, Sunday & Monday

"Established 1997"

Patient Name: Repeat Customer: Yes No

Age: Height: Original Fur Color/Type:

Has Patient ever had professional medical attention before? Yes No

Is he/she allergic to any medication? : Yes No

Description of patient's injury/ailment:

Patient/Guardian Name:

Address:

City: State: Zip:

Phone# (Daytime): Phone Evening: Mobile:

Email Address:

Owner's Electronic Signature:

Date:

I have read the hospital policies listed below in the pink box and agree to them: Yes No

This section is for Hanna Bruce Bears & Teddy Hospital®

We provide a written Estimate for your review (Whether or not the patient is here or you send us photos for review). The fee for the estimate is $30. Once the written estimate is approved the $30 fee is waived and a 50% deposit of the total invoice is required and the balance is due at the time of the scheduled surgery and discharge from the hospital. If the estimate is not approved the $30 fee is non-refundable. If your patient is here there will be a return shipping charge. We have flat fees for most of our services, and we charge for materials for repair plus return shipping. If sending a check please include your DL# on the check. If paying by credit card you can enter that information on the form by your signature. Click Below to make a secure payment.

Click Here→

Please Note: We insure all our patients at the hospital for $500 during their stay and when they are shipped home. If your patient is professionally appraised at a higher value, please include a copy of that appraisal in the box with the patient. If you would prefer to fax your admitting form the number is 717-626-3155.

Thank you for choosing our teddy hospital for your patient's care!

Send mail to webmaster at teddydoctor@hannabrucebears.com with questions or comments about this web site. Graphics are used only by permission. Copyright © 1997 Hanna Bruce Bears & Teddy Hospital ® Heart and Soul Bears Last modified: 04/21/2008 07:32:40 AM