New Patient Registration Form test

    Owner Name:
    Last Name:
    Co-Owner Name:
    Telephone:
    Cell:
    Other:
    Address:
    City:
    State:
    Zip Code:
    County:
    (County Required for Rabies Vaccination)
    Email:
    Employer:
    Phone:
    How did you hear about us?

    Pet Information #1

    Name:
    Type of Pet:
    Breed:
    Color:
    Sex:
    Neutered/Spayed
    Birthday:
    Estimate:

    Pet Information #2

    Name:
    Type of Pet:
    Breed:
    Color:
    Sex:
    Neutered/Spayed
    Birthday:
    Estimate:

     

    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.

    Date :

    Client Signature*
    Please type your name below:



    Check to confirm submission.