WELCOME To Eagle River Animal Hospital!

WELCOME!
Thank you for giving us the opportunity to care for your pet. Please fill in the information below as completely as possible.
REGISTRATION
Name
Spouse's Name
Owner Work Phone
Spouse Work Phone
Owner Cell Phone
Spouse Cell Phone
Primary Contact #
Address

Mailing Address

Street Address Line 2

City State

Zip
Email Address
example@example.com
Alternate/Emergency Contact Name
Alternate Contact Phone
Owner's Occupation
Owner's Employer
Owner's Driver's License
Spouse's Occupation
Spouse's Employer
Spouse's Driver's License
I am eighteen (18) years or older and I am responsible for all charges incurred. I also understand that these to be paid for at the time of service and that a deposit may be required for hospitalized or charges will need surgical patients.
Signature

Clear
Date

Month Day Year
Date
My Payment Method

Cash Check Care Credit Credit Card
There will be a 1.5% interest service charge added to all accounts with a balance over thirty (30) days. A $30 fee will be applied for a check presented with insufficient funds. All collection fees, if applicable, will be added to the account balance.
How did you learn of our clinic?

Website Outdoor Sign/Location Previous Pets Newspaper Yellow Pages Referral Other (please specify)
By whom?
Please specify?
Please verify that you are human *
Should be Empty:

WELCOME!