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. 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
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