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Client Information Form
Thank you for giving us the opportunity to care for your animals. To help us better serve you, please complete the following:
*
Indicates required field
*
Indicates required field
Name
*
First
Last
Co-Owner or Spouse Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Home Phone
*
Mobile Phone
*
Spouse's Cell Phone
*
Email
*
Spouse's Email
*
Place of Employment
*
Business Address
*
Phone
*
Spouse's Place of Employment
*
Business Address
*
Phone
*
How did you become aware of our clinic?
*
Google or Social Media
Drove By
Personal Recommendation
Whom may we thank?
*
Pet Information
Pet Name
*
Species
*
Canine
Feline
Other
Sex
*
Male
Neutered Male
Female
Spayed Female
Breed
*
Color/Markings
*
Microchip ID Number (if applicable)
*
Pet's Birth Date
*
Additional Pet Information
Pet Name
*
Species
*
Canine
Feline
Other
Sex
*
Male
Neutered Male
Female
Spayed Female
Pet's Birth Date
*
Breed
*
Color/Markings
*
Microchip ID Number (if applicable)
*
TERMS
We accept cash, check (SSN required) , Debit card, Visa, MasterCard, Discover, and American Express.
Client agrees to pay a service charge of 1.5% per month plus a $1.00 per month billing fee - 18% per annum on account not paid in 30 days.
If this account is assigned to an outside agency for collections, I/we agree to pay all attorney's fees, court costs, process service fees, filing fees, and any other charges or fees, up to 40% that may be assessed by any collection agency retained to pursue this matter with or without suit.
Collection procedures will be started 60 days after the date of service.
Signature
*
Please type your name here. This will serve as your signature to agree to the terms stated above.
Date
*
Agree to Terms
*
Agree
Submit
Home
About Us
Veterinarians
Services
Wellness Exams
Vaccinations and Microchips
Dentistry and Surgery
X-Ray and Ultrasound
Medications and Diet
Laboratory Services
Large Animal Services
Client Center
Client Forms
Petly
Contact