Indian Tree Animal Hospital Client Information & Financial Agreement

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Cell Phone

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

Co-Owner Phone

Please enter a valid phone number.

Employer

Email (We use this to remind you of vaccinations due and send you email-only ITAH promotions)*

example@example.com

How Did You Hear About Us?

Pet Name #1*

Breed

DogCat

Birthdate/Age

Coloring

MaleFemale

YesNo

If yes, what is the tag #?

YesNo

Which pet insurance company is your pet insured under? (So we may submit your claims for you)

Previous Veterinarian - Name & Phone Number (So we may obtain medical history)

Yes

YesNo

Pet Name #2*

Breed

DogCat

Birthdate/Age

Coloring

MaleFemale

YesNo

If yes, what is the tag #?

YesNo

Which pet insurance company is your pet insured under? (So we may submit your claims for you)

Previous Veterinarian - Name & Phone Number (So we may obtain medical history)

Yes

PAYMENT IS DUE IN FULL AT TIME SERVICES ARE RENDERED

I understand that if I do not pay this account as agreed, the account is subject to costs of collection, attorney fees, and including interest (any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum). Returned check fee is $40. I understand that the hospital staff will provide an estimate of current and anticipated charges any time I request one. I am requesting that veterinary care be provided for pets presented by me or my agents. I understand that I am financially responsible for all services provided. For hospitalized cases, a deposit may be required in advance. By submitting this form I agree to the payment terms above.

WE ACCEPT THE FOLLOWING: CASH, CHECK, MASTER CARD, VISA, DISCOVER, & AMERICAN EXPRESS. WE CAN ARRANGE FOR CareCredit, ASK OUR RECEPTIONIST FOR DETAILS.

By signing below, I agree to the terms of the above policies.

Today's Date

Date

Client Information & Financial Agreement

Owner Information

Current Pet Information

Pet # 2 Information

Payment Policy