Thank you for allowing us the opportunity to care for your pet. So that we may become better acquainted, please complete the following:
Client (Owner) Information
*
First Name
Last Name
Secondary Owner
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Pet's Name
*
Species
*
Please Select
Dog
Cat
Bird
Rabbit
Reptile
Other
Please specify "Other" Species
Breed
*
Age or Birthdate
*
Sex
*
Please Select
Male
Neutered Male
Female
Spayed Female
Unknown
Color(s)
*
Do you have another pet to add?
*
YES
NO
Pet's Name
*
Species
*
Please Select
Dog
Cat
Bird
Rabbit
Reptile
Other
Please specify "Other" Species
Breed
*
Age or Birthdate
*
Sex
*
Please Select
Male
Neutered Male
Female
Spayed Female
Unknown
Color(s)
*
Do we have permission to use your pet's images on our hospital's social media pages?
*
YES
NO
Accepted Payment Methods:
Cash, Credit/Debit Card, Care Credit
Checks are NOT accepted
Payment Policy
I understand that payment is required in full when services are rendered. Maywood Veterinary Clinic does not accept payment on account. In the case of non-payment, I will be responsible for a collection agency fee of $16.00 and/or attorney fees necessary to collect the full amount due to The Maywood Veterinary Clinic. I further understand that, in the case of non-payment, a finance charge of 1.5% per month (18% APR) will be charged.
Signature
*
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