New Client Form

Thank you for giving our hospital the opportunity to care for your pet. So that we may better able to meet your needs, please complete the following:

Your First Name: *

Your Last Name: *

Husband or Wife's First & Last Name:

Mailing Address:

ZIP:

Home Address (if different):

ZIP:

Home Phone: *

Your Work Phone:

Ext.:

Cell Phone:

Email Address: *

Husband or Wife's Work Phone:

Your Place of Employment:

Husband or Wife's Place of Employment:

In case of Emergency, name of nearest relative who doesn't live with you: (Name, Address, City and Phone)

If Other (Name):

If Personal Recommendation - whom may we thank?:

Has your pet been to a Veterinarian /Clinic?:YesNo

Pet's Name:

Breed:

Born:

Sex:

Spayed/Neutered:YesNo

Color:

Is your pet on Heartworm prevention?:YesNo

If you checked yes to this question please answer the following:

Daily:

Monthly:

Brand:

Reason for visit:

Method of payment for services:CASHCHECKCREDIT CARD

PAYMENT IS DUE WHEN SERVICES RENDERED. IF YOU HAVE ANY FINANCIAL CONCERNS WE WILL GLADLY PRINT UP AN ESTIMATE BEFORE SERVICES ARE RENDERED.

ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY: This information is accurate and true to the best of my knowledge. I understand that I am responsible to pay for services rendered, including reasonable attorney's fees and costs of collection in the event of default. I further understand that if payment becomes 30 dayspast due, delinquency Charge s at the lesser of the annual rate of 18%, or the maximum allowable rate, will be due on delinquent amounts from the date the payment was due.

Name(s) of Responsible Client(s): *

Date *

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