New Client Form printable pdf download

New Client Form

All Pets - New Client Form

Date________________

Your Name _____________________________________ Spouse’s Name _____________________________

Address________________________________________City _________________St.______Zip___________

Home Phone____________________Cell Phone____________________Wk Phone_____________________

Your Employer _________________________Phone_________________May we contact you there?______

Driver’s License Number_______________________ Must give DL # to write checks

Spouse Employer________________________Phone________________May we contact you there?______

E-mail address for newsletters or reminders: _________________________________________ (optional

and it will absolutely not be sold or shared)

How did you hear about us?

_____Client

Client whom we may thank_____________________________

_____Other ____________________________

PAYMENT IS DUE IN FULL AT THE TIME SERVICES ARE RENDERED

I understand that if I do not pay this account as agreed, the account is subject to costs of collection,

attorney fees, and including interest (any balance that is carried over a period of 30 days will accrue a

monthly finance charge of 1.5% or 18% per annum). Return check fee is $30. I understand that the

hospital staff will provide an estimate of current and anticipated charges any time I request one. I am

requesting that veterinary care be provided for pets presented by me or my agents. I understand that I am

financially responsible for all services provided.

Signature___________________________________________Date________________

Pet #1

Pet #2

Pet #3

NAME?

New Client Form