EAGLE RIVER ANIMAL HOSPITAL WELCOME FORM

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

Owner's Name

Work Phone

Cell Phone

Spouse's Name

Spouse Work Phone

Spouse Cell Phone

Mailing Address

Address

Street Address Line 2

City State

Zip Country

Home Phone

Email Address

Owner's Occupation

Owner's Employer

Spouse's Occupation

Spouse's Employer

Alternate/Emergency Contact Name

Emergency Contact Phone

If someone referred you to us, please share their name here:

How did you learn of our clinic?

Newspaper Website Referral Outdoor Sign/ Location Previous Pets Yellow Pages

I am eighteen (18) years or older and I am responsible for all charges incurred. I also understand that these charges will need to be paid for at the time of service and that a deposit may be required for hospitalized or surgical patients.

Signature

Clear

Date

My Payment Method:

Cash Check Care Credit Credit Card

(If paying by check, SSN & driver's license will be required)

There will be a 1.5% interest service charge added to all account s 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.

WELCOME!

REGISTRATION