New Client Form

 

 

New   C lient   F orm  

 

Owner’s   F irst   N ame:______________________________     O wner’s   L ast   N ame:____________________________________  

Home   P hone:_____________________________________     M obile   P hone:_______________________________________  

Work   P hone:________________________________________     F ax   N o:__________________________________________  

Home   A ddress:________________________________________   C ity:_________________   S tate:______   Z ip:___________  

Email   A ddress:_______________________________________________________________________________________  

Occupation:_________________________________________________________________________________________  

Spouse:________________________________________   S pouse   E mail:_________________________________________  

Other   P erson   T o   C ontact   F or   E mergencies:_________________________________________________________________  

Send   E mails   f or:         _ ____Reminders         _ ____Statements         _ ____Promotions/Contests         _ ____Do   n ot   s end   m e   e mails  

Drivers   L icense/Identity   C ard:____________________________________________________________________________  

How   d id   y ou   h ear   a bout   u s?_____________________________________________________________________________  

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*Name   o f   P et:_______________________________________     D ate   o f   B irth:_____________________     A ge:____________  

(Circle   O ne)    

Dog           C at  

 

 

Male   Female                

 

Spayed           N eutered           I ntact  

Other:___________________________     B reed:____________________________     C olor:___________________________  

Microchip:_____________________________     L ocal   A uthority   L icense:______________________________     ( City   L icense)  

********  

*Name   o f   P et:_______________________________________     D ate   o f   B irth:______________________     A ge:___________  

(Circle   O ne)    

Dog           C at  

 

 

Male   Female                

 

Spayed           N eutered           I ntact  

Other:___________________________     B reed:____________________________     C olor:___________________________  

Microchip:_____________________________     L ocal   A uthority   L icense:______________________________     ( City   L icense)  

********  

*Name   o f   P et:_______________________________________     D ate   o f   B irth:______________________     A ge:___________  

(Circle   O ne)    

Dog           C at  

 

 

Male   Female                

 

Spayed           N eutered           I ntact  

Other:___________________________     B reed:____________________________     C olor:___________________________  

Microchip:_____________________________     L ocal   A uthority   L icense:______________________________     ( City   L icense)  

 

I,   t he   u ndersigned,   h ereby   a gree   t o   p ay   T he   W ellPet   C enter   a ll   a mounts   a nd   c harges   h ereafter   i ncurred   b y   m yself   a nd/or   m embers   o f   m y   f amily   f or   m aterials   f urnished  

and   s ervices   r endered   b y   T he   W ellPet   C enter.     T he   a mount   s hown   o n   t he   b ooks   a nd   r ecords   o f   T he   W ellPet   C enter   s hall   b e   d ue   o n   d emand   a nd,   u pon   d efault.     I   a gree   t o  

pay   c osts   o f   c ollection,   i ncluding   a ttorney   f ees   a nd   c ourt   c osts.     I n   t he   c ase   t hat   T he   W ellPet   C enter   p ursues   d ebt   t hrough   t he   c ourt   s ystem,   I   w aive   a ll   r ights   o f  

exemption   a s   t o   p ersonal   p roperty   u nder   t he   l aws   o f   T exas   o r   a ny   o ther   s tate.  

 

_____________________________________                                         _ _____________________________________________________  

 

 

   

Date  

 

 

 

 

 

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