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. ___
Spouse / Other
Apartment #: _______ City:_________________________________ State:______________ Zip: ___________
Phone: Preferred:_______________________ Work: _______________________________
Home: __________________________ Spouse / Other : ______________________
( 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: _________________