Client-Information Care Animal Center

The Doctor's and Staff at Care Animal Center welcome you. Thank you for giving us the opportunity to care for your pet(s Please help us better meet your needs by taking a few moments to fill out and sign the following client and patient information sheets.

Owner Name

Spouse/Other

Address

City

State

Zip.

SSN

Spouse/Other SSN

Date of Birth

Date

Spouse/Other Date of Birth

Date

Home Phone

Cell Phone

Email Address

example@example.com

Employer's Name & Address

Work Phone

Spouse/Other Employer Name & Address

Spouse/Other Cell Phone

Spouse/Other Work Phone

Did someone refer you to our hospital? If so, whom may we thank?

We will gladly prepare a written estimate if you so desire. Please ask a receptionist or doctor. Professional fees are due at the time services are rendered. If you wish to pay by check or credit card, please complete the following:

Owner Driver's License and State

Spouse/Other Driver's License and State

Preferred Method of Payment

CashCheckCredit Card

DUETO STATE LAW, ALL DOGS & CATS MUST BE CURRENT ON RABIES VACCINATION To help prevent the spread of infectious diseases, hospitalized and boarded animals must be current on required vaccinations. Proof of vaccination must be presented at time of check-in or vaccinations will be administered.

I understand every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care and handling. I hereby authorize this hospital to receive, prescribe for, treat or perform surgery upon the pet(s) listed on this form and additional pets I present. Furthermore. I agree to pay fees for services rendered at the time the pet is discharged from the hospital or as agreed prior to treatment. I agree to pay for the reasonable cost of collection in the event that collection efforts become necessary. AGREEMENT TO PAY:1, undersigned, accept the fee charged as a legal and lawful debt and agree to pay said fee, including any/all collection agency fees, (33.33%), attorney fees and/or court costs. if such be necessary. You agree. in order for us to service your account or to collect monies you may owe. Care Animal Center and/or our agents may contact you by telephone at any telephone number associated with your account. including wireless telephone numbers. which could result in charges to you. We may also contact you by sending text messages or emails. using any email address you provide to use. Methods of contact may include using pre-recorded/artificial voice messages and/or use of automatic dialing device, as applicable.

I/We have read this disclosure and agree that Care Animal Center. its employees and/or agents may contact me/us described above. I understand that a reasonable service fee will be assessed for each non-sufficient fund check and/or certified letter that must be sent. I understand that veterinary service is provided during nighttime hours as necessary in the judgment of the veterinarian on call. Continuous presence of qualified PERSONNEL MAY OR MAY NOT BE PROVIDED If I neglect to pick up my pet within one week of the discharge date and fail to notify this hospital within that time period. steps as described by law will be undertaken to consider my pet(s) abandoned

Signature of Responsible Party

Date

Client Information