WELCOME To Eagle River Animal Clinic!

Thank you for giving us the opportunity to care for your pet. Please fill in the information below as completely as possible.

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 Country

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

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 *

WELCOME!

REGISTRATION