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New Client Information

 

CLIENT INFORMATION FORM

Hello! We are glad you’re here!                                                                                 DATE: ____________________

Thank you for giving us the opportunity to care for your pet.  Please help us meet your needs by completing this registration form.

 

Mrs. ___ Mr. ___ Ms. ___ Dr. ___

 

Name: ______________________________________________________________________________________________________

                                                (Last)                                                                                           (First)

Spouse / Other

Name: ______________________________________________________________________________________________________

                                                (Last)                                                                                           (First)

 

Address: ____________________________________________________________________________________________________

Apartment #: _______          City:_________________________________                   State:______________              Zip: ___________

 

Phone:    Preferred:_______________________                         Work: _______________________________                                                                                                                      

                 Home: __________________________                     Spouse / Other : ______________________

                 Cell: ____________________________                                                                                    

 

Email:  ______________________________________________________________________________________________________

( for appointment reminders and to receive your pet’s testing results)

 

Employers Name and Address: __________________________________________________________________________________

 

Spouse/Other’s Employer:        __________________________________________________________________________________

 

Driver’s License No. ____________________________ State Issued:______  Social Security Number: _________________________

 

How did you hear about us? ____________________________________________________________________________________

If referred by a friend, include their name so we can thank them _______________________________________________________

 

All professional fees and payment for any goods or services are due at time of service.  Our office does not do any billing of accounts.  We accept Care Credit as a form of payment. Please ask if you have any questions prior to your appointment.

 

Deposits are required for most services or procedures.

 

If your account has a balance, a service charge of 1 ½ % per month (18%  annually, $1.00 minimum) will be added to your account. If your account is sent to our Collection Agency, you will be responsible for any and all fees, including attorney and court cost.

 

I have read and agree to all terms before mentioned:

 

 

Signed: ______________________________________________________________________________  Date: _________________

Contact Us

We look forward to hearing from you

Location

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Office Hours

Our Regular Schedule

Monday:

8:00 am-6:00 pm

Tuesday:

8:00 am-6:00 pm

Wednesday:

8:00 am-6:00 pm

Thursday:

8:00 am-6:00 pm

Friday:

8:00 am-6:00 pm

Saturday:

8:00 am-12:00 pm

Sunday:

Closed