New Client Form

Welcome to Best Friends!

Please take a few minutes to fill out the information below before your appointment.
Full Name*

First NameLast Name
Spouse / Significant other Name - allowed to make decisions for your pets

First NameLast Name
Phone Number

Area CodePhone Number
Alternate or Emergency Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Patient name:blanks* Age: Breed: blank Male Female Spayed/Neutered?
Patient name:blanks Age: Breed: blank Male Female Spayed/Neutered?
Patient name:blanks Age: Breed: blank Male Female Spayed/Neutered?
How did you hear about us?*
Other, please specify*

Please fill out information if you were referred to us by another client:

	Full Name	Contact Number
1
2

Previous veterinarian - may we call for records?
By submitting this form, I understand that:

·          Payment is expected, in full, at the time services are rendered. We do not accept payments or offer any payment plans.

We accept Care Credit, Discover, Master Card, VISA, debit cards, and Cash only.

·          I understand that a deposit of 50%of the estimate may be required before services are performed.

·          A 1.5% monthly (18% annual) service fee is charged to any account with an unpaid balance.

·          It is understood that an estimate of charges will be given for services when requested.

·          I assume full financial responsibility for all charges incurred by my pet. I realize that these charges may exceed a given estimate if complications arise. I understand that I will be contacted prior to treatment, if possible, should complications occur.

·          In order to keep our costs down it is our policy to pursue all delinquent accounts.

·          Should I abandon my pet at this facility, I understand and agree to allow Best Friends Animal Health Center to treat my pet in the event of an emergency. I agree I am responsible for emergency fees that incur during my pet’s stay. I also acknowledge Best Friends Animal Health Center may assume ownership of my pet in 10 days if my pet has been abandoned due to hardship or lack of payment.

·          Should my account be turned to collections, for any reason, I authorize Best Friends Animal Health Center to release medical records and all client and patient information to the necessary person(s) tasked to collect this debt.   I agree to assume collection costs including, but not limited to, collection agency fees, attorney fees, court costs and/or any other associated fee(s).

·          My submission of this form confirms that I have read and understood the above.
Please attach any records you may have for your pet(s)

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Welcome to Best Friends!