New Patient Registration Form

Pet Information #1

Pet Information #2

PAYMENT IS DUE IN FULL AT THE TIME SERVICES ARE RENDERED

I understand that if I do not pay this account as agreed, the account is subject to all costs of collection, attorney fees, and interest on any balance that is carried over a period of 30 days with a monthly finance charge of 1.5% or 18% per annum. Any check returned will be subject to a return check fee of $35.00. I understand that the hospital staff will provide an estimate of current and anticipated charges upon my request. 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. By submitting this form I agree to the payment terms above.