Client Information Form
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Owner's Name *
Email
If provided we can send updates for vaccine reminders for your pet
Address *
City *
State *
Zip *
Drivers License Number
Home Phone
Work / Cell Phone *
Parent / Spouse Info
Is this info in reference to a parent or spouse?
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Spouse / Parent Name
Parent / Spouse Phone
Parent / Spouse Employer/Occupation
Parent / Spouse Work Phone
Parent / Spouse Address
How did you become aware of our clinic?
If referred, who can we thank?
Planned method of payment
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Do you give us permission to use pictures of your animal on our web pages?
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ALL FEES ARE DUE AND PAYABLE UPON COMPLETION OF SERVICE. PAYMENT IN FULL IS EXPECTED WHEN TREATMENT IS PERFORMED OR ANIMAL IS DISCHARGED. IN CASE OF EMERGENCY HOSPITALIZATION, DEPOSIT MUST BE MADE WITH THE RECEPTIONIST. ON YOUR REQUEST WE WILL PROVIDE YOU WITH A WRITTEN ESTIMATE OF FEES BEFORE CARE IS PROVIDED.
A FINANCE CHARGE WILL BE ADDED TO YOUR ACCOUNT FOR ANY UNPAID CHARGES AFTER 30 DAYS. THE FINANCE CHARGE WILL BE COMPUTED AT A PERIOD RATE OF 1.50% PER MONTH WHICH IS THE ANNUAL PERCENTAGE RATE OF 18%. THE MINIMUM CHARGE WILL BE $2.00. ANY ADDITIONAL CHARGES DUE TO COLLECTION OF THIS ACCOUNT SUCH AS COURT COST, ATTOORNEY FEES, ETC., WILL BE BILLED TO YOU. BY SIGNING YOU ASSUME ALL RESPONSIBILITY OF ALL CHARGES ON THIS ACCOUNT.
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