Client Information Sheet

Name*

Owner's First NameLast Name

Address*

Address

Street Address Line 2

CityState

Zip Code

Primary Phone Number *

Email Address*

example@example.com

Driver's License #*

Secondary Contact

Spouse/Partner's First NameLast Name

Secondary Number

How did you hear about our hospital?

Pet's Name*

Birthdate/Age*

Species*

DogCat

Gender*

Intact FemaleSpayed FemaleIntact MaleNeutered Male

Breed*

Color

Reason for your Visit*

We will gladly prepare a written estimate upon request. Payment is due at the time services are rendered. We accept cash,major credit cards and Care Credit.

The undersigned, assume all financial responsibility for charges incurred and accrued to the patient listed above or any other pet owned by me. I realize that if I fail to pay, I will be charged interest, at the rate of 18% per annum or the legal rate of interest, whichever is greater and billing fees. I acknowledge, should I be placed with a collection agency or attorney for non-payment, I agree to pay all costs of collections, attorney fees and costs, court costs, and interest, at the rate of 18% per annum or the legal rate of interest, whichever is greater.

Owner's Signature*

Date