LL - Client Consent Form

Client Consent Form

Thank you for choosing Lucks Lane Veterinary Clinic. Please complete this form after scheduling your appointment with our Front Desk Team. (804) 594-3545
Date of Appointment*

MonthDayYear
Date
Client Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Cell Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Pet's Name*
Species*
Sex of Pet*
Spayed / Neutered?*

YesNoUnknown
Age*
Please specify if the age is in weeks, months, or years.
Breed
Breed of pet. If unknown, please leave blank.
Color*
Social Media Consent - I give permission for Lucks Lane Veterinary Clinic to use my pet's picture and name on our social media sites, website, or any advertising materials.*

YesNo
TERMS & CONDITIONS

I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE. THE UNDERSIGNED JOINTLY AND SEVERALLY GUARANTEE PAYMENT. I AGREE TO REIMBURSE LUCKS LANE VETERINARY CLINIC THE FEES OF ANY COLLECTION AGENCY, WHICH MAY BE BASED ON A PERCENTAGE AT A MAXIMUM OF 32% OF THE DEBT, AND ALL COSTS AND EXPENSES INCLUDING ATTORNEY FEES IN SUCH COLLECTION EFFORTS.

PAYMENT OF ALL FEES IS REQUIRED AS SERVICES ARE RENDERED.

THERE WILL BE A $30.00 SERVICE CHARGE FOR ANY AND ALL RETURNED CHECKS.

By signing below, you agree that you have read this form and are aware of the above payment policy.
Signature*

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