CLIENT INFORMATION SHEET

Thank you for choosing the LVVC. We appreciate you!

Name

Spouse/Significant other

Address

Mailing Address

Street Address Line 2

City

State

Zip Code

Street Address If different from mailing address

Cell #(self)

Cell #(spouse/sig)

Home #

Work #(self)

Work #(spouse/sig)

Employer (Self)

Employer (spouse/sig)

Are you at least 18 years of age or older?

YESNO

EMail Address

example@example.com

May we text and/or email regarding important appointments and vaccine reminders?

YESNO

Others allowed to request services/medications and/or bill to my account (if applicable), must be at least 18 years old:

3

4

5

Please be advised that it is your responsibility to come in and remove someone listed above if they are no longer allowed to request services/medications or bill to your account. Phone calls will not be accepted.

I understand and agree that payment for services rendered by Lahontan Valley Veterinary Clinic is expected after each visit. I also understand that Lahontan Valley Veterinary Clinic is not staffed 24 hours a day, and my pet(s) will not have overnight medical supervision.

How will you be paying for each visit?

If paying by check we have a $30.00 return check fee for any check that is returned unpaid.

If prior arrangements have been made for payment the following will apply: Any unpaid balances will be billed on a monthly basis. Any balances unpaid for more than 30 days are subject to an 18% interest charge. A payment on account is due a minimum of every 30 days. If no payment is received within 60 days this account will be turned over to small claims court or our collection agency. You agree to reimburse us the fees of any collection agency, which may be based on a percentage at a maximum of 30% of the debt, and all cost and expenses, including reasonable attorney fees, we incur in such collection efforts.

Social Media Release (Initial)

By initialing, I consent to allowing photos, video and information related to my pet or its medical case to be uploaded to any and all social media outlets. I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown. And I waive any right to royalties or other compensation arising from or related to the use of the image.

I also understand that by signing below this contract will remain in effect until further notice. This contract will cover all services rendered by Lahontan Valley Veterinary Clinic for any animal on file with you.

Print

Date

Signature

Date