Bush Animal Hospital Client Information Form

Check in instructions: Our lobby is open, please feel free to check-in in person. Please have your pet(s) secure while on our property. For dogs: Properly fitted collar attached to a leash. For cats: Secured in a carrier. We are near a busy intersection and your pet's safety is our top priority.

Missed Appointment Policy: We ask you to please give 24 hours notice when possible. We understand situations occur that may result in you being unable to make it to your appointment and kindly ask you to give as much notice as possible. We can be reached by phone or email for cancellations and rescheduling. We will charge for our Doctor's time upon a 3rd consecutive missed appointment.

Financially Responsible Party / Primary Owner

First Name Last Name

Home Phone

Cell Phone Number

Area Code Phone Number

Driver's License Number

Email

example@example.com

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Employer

Employer Phone

Mailing Address (if different)

Full Legal Name

Relationship to Primary Owner

Cell Phone

Email Address

example@example.com

Employer Name

Employer Phone Number

Area Code Phone Number

List of All Current Patients

Payment Policy: Payment is due at the time of service. As a courtesy to you we try to provide written estimates when possible. If you haven't received one and would like one, please ask. By signing this form you acknowledge that you are aware you are financially responsible for any and all services and products provided and that there is a monthly 1.5% finance fee with a minimum of $3.00 charge to any unpaid balance. For your convenience we accept cash, checks (with identification), most major credit cards as well as Care Credit.

Signature of Primary Owner (Financially Responsible Party)

Clear

Date

Were you referred to us? If so, who can we thank?

Secondary Owner (If Applicable)