If you are a new client or adopted a new pet, please fill
out the following form. When you click submit your
information will be sent to your office and we will be ready
to serve you.
You:
Last Name:
First Name:
Spouse:
Address:
City / State:
Zip:
Driver's License Number:
(Required for ALL Check Payment)
Phone:
Cell Phone:
Email Address
(For Reminders)
Employer:
Occupation:
Work Address:
Work Phone:
Pet 1:
Pet's Name:
Breed:
Age:
Birth Date:
Color:
Animal Type:
Sex:
Status:
Date of Last Vaccines:
Distemper Vac.
Date:
Rabies Vac. Date:
Other Vaccine:
Other Vac. Date
Pet 2:
Pet's Name:
Breed:
Age:
Birth Date:
Color:
Animal Type:
Sex:
Status:
Date of Last Vaccines:
Distemper Vac.
Date:
Rabies Vac. Date:
Other Vaccine:
Other Vac. Date
For Us:
In case of emergency,
please give us the name and phone number of a close relative or
friend.
Name:
Address:
Phone:
How did you hear about us:
Financial Policy:
In order to control
hospital costs for services we request that the charges for office
visits and treatments be paid at the time of service, unless prior
arrangements have been made with our Business Manager.
In the event payment
under this agreement is not made at the time and the manner
required, the undersigned agrees to pay all costs of collection,
including attorney fees, court costs, filing fees, and charges or
commissions, up to 50%, that may be assessed to us by a collection
agency, or attorney retained to pursue the matter, with or without
suit.
There will be a
fee of $20.00 for returned checks. A 1.5% per month (18% per year)
finance charge will be assessed on unpaid balances.
Submission:
I have read the
Financial Policy above and agree to the terms and conditions:
Yes No
Agreed To By:
Date:
