Lake Forest Animal CIinic

                                                              Client Information

Dr___Mr.____

Mrs___Ms____

Last  Name:                                    First                                    Spouse                              

Address:                                            City:                                                   Zip:                 

Home Phone:                                               Cell Phone:                                                     

Email Address                                                                                                                    

Occupation/Title:                                                        Employer                                          

Employer's Address:                                                  Work Phone_                                     

Spouse's Occupation/Title:                                          Employer:                                         


Employer's Address:                                                  Work Phone:                                                    

Nearest Relative:                                                        Phone                                               

Have you had other pets treated here previously?   (circle)            Yes                  No

Who Referred You: Please Circle:

Yellow pages   Clinic sign         Animal Shelter     New Homeowner Letter    Advertisement   Website

Personal Referral Name                                                                                   

(We would like to send them a thank you note.)

I understand that professional fees are to be paid at the time services are rendered and that deposits are required on all hospitalized Patients. Cash, Check, Visa, MasterCard and American Express are accepted for your convenience. IF YOU PLAN ON WRITING CHECKS, PLEASE HAVE YOUR DRIVER'S LICENSE AVAILABLE SO WE MAY COPY IT FOR YOUR FILE.  There will be a $25.00 service charge imposed for all returned checks. If your check is returned, you could be liable for three! times the amount of the check or $100.00, whichever is greater, in addition to the face value of the check, Court costs and fees.

By signing below, YOII are hereby agreeing to pay all collection fees, attorney's fees and costs in the event of collection or legal action to enforce payment of monies due. A late charge will be imposed on all accounts over 30 days at 1-½ % per month or 18% per annum.

I AGREE AND CERTIFY THATTHE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE.

Owner’s Signature________________________________________  Date:_____________

FOR OFFICE USE-ONLY:

Date ________

Recptionists Intials:_________