Sandhills Animal Hospital Client Information Sheet

Sandhills Animal Hospital

Client (Owner) Information Sheet. Thank you for giving us the opportunity to care for your pet. Please help us better meet your needs by taking a moment to complete the following information.
Date

Month Day Year
Date
Name

First Name Last Name
Phone Number

Area Code Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How did you learn of our practice? (Please check as many as apply)

Phone book Referral Saw clinic in passing Other
Professional fees are due at the time services are rendered. Method of payment:

Cash Check Visa MC Care Credit Debit
If a balance does occur, a 1.5% per month or flat billing fee of $4.00 per month, whichever is greater, whill be charged. IF payment arrangements should be necessary, let us know before services are rendered. Thank you.
Signature

Clear
Employer/Phone/Address
Names of other people that may be bringing your animal (s) in to the clinic (children, parents, etc.)
We consider our pet(s),

Part of the family & want the best care Part of the family but there are some limits with regards to money Just as pets
Is there someone else you would like us to call in case of emergency if we cannot reach anyone at any of the above telephone numbers? Please names and phone numbers.
Should be Empty:

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