IVH Client Intake Form

Name*

First NameLast Name

Spouse/Co-owner Name

First NameLast Name

Business Name (if Applicable)

Business Federal Tax ID

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Physical Address ( if differs from mailing address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home/Cell Phone*

Work Phone

Alternate Cell Phone

E-mail*

example@example.com

Social Security Number

Drivers License

Issuing State

Employer Name/Business

Employer Address

Doctor Preference? (Check if applicable)

Dr. Nick JohnsonDr. Richard BeekmanDr. Kelsey Martin

Who can we thank for referring you? (Location/Hospital Sign, Google, Yellow Pages, Promotion, Website/Facebook, Internet, Family/Friend)

Are your livestock/pet(s) allowed to be part of our Social Media?

YesNo

Previous Veterinary Hospital

Phone Number

I hereby authorize Intermountain Veterinary Hospital to provide treatment for any livestock/pet(s) I bring to IVH for services and understand that I am financially responsible to Intermountain Veterinary Hospital for all charges incurred during or due to a result of my visit. I agree to pay all charges promptly upon presentation thereof unless prior arrangements have been agreed upon in writing. I understand that this will continue to apply future livestock/pets and future services provided by Intermountain Veterinary Hospital. I agree to pay all service charges, collection, legal and court fees in the event it becomes necessary to pursue my account for collection. I have read, understand and agree to all terms of the Care and Payment Policy on the reverse of this form. I am entitled to a copy of this agreement at the time I execute said agreement and hereby acknowledge receipt of this form. I give my permission to Intermountain Veterinary Hospital to release vaccination information to other veterinarians, city or county officials, kennels or groomers as necessary.

Client Signature*

Clear

Date*

Date

Payment in full is due at time of service. We accept payment via cash. check. Visa, MasterCard and Discover. Sorry, we do not accept out-of-state checks. For all check payments and accounts allowed to charge we require a copy of your driver's license. A deposit of 30-50% may be required for all major surgeries and/or hospitalization. The deposit is due at the time the patient is admitted. The entire balance is due at the time of discharge. Emergency cases require a minimum deposit of $150 before we can begin extensive medical procedures. Emergency first aid may be initiated immediately without a deposit (if necessary, to minimize acute pain or save an animal's life A billing charge of $3.00 per month for billing and postage costs will be added to all open accounts if not paid within 30 days. A finance charge of 1.50% per month (equivalent to 18% annually) will be charged to all accounts not paid in full within 30 days. Additional services will not be provided or charged to accounts with outstanding balances older than 30 days.

There will be a $30 fee for returned checks.

Should your account be referred to an outside collection agency. you hereby agree to pay all collection costs, attorney fees and court costs. The proper venue for any action filed to enforce the terms of this agreement will be Gallatin County, MT. By signing below, I am personally guaranteeing payment of any and all amounts due on this Intermountain Veterinary account. This includes the principal amount owed and all additional costs and fees of account collection including, but not limited to, attorney fees, collection agency fees that may be up to 50% of the amount owed, court costs, debit/credit card transaction fees, and interest at the highest amount allowed by law. These costs and fees are actual costs that are incurred, and these costs and fees result in a monetary loss due to Consumer's failure to pay.

Client Signature*

Clear

Date*

Date

INTERMOUNTAIN VETERINARY HOSPITAL

CLIENT INFORMATION FORM