Client Forms

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

Pet Information

Pet Name *

Breed *

Color/Markings *

Microchip ID Number (if applicable) *

Pet's Birth Date *

Additional Pet Information

TERMS
We accept cash, check, debit card, Visa, MasterCard, Discover, and American Express.
We CANNOT accept personal checks without a Social Security Number.
Client agrees to pay a service charge of 1.5% per month- 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 *

Permission to Use Photograph

Owner's Name *

First

Last

Pet Name(s) *

I grant permission to Countryside Animal Clinic employees to take photographs of my pet. I agree that they may use the photographs in illustrations, advertising, publicity and web content.

I have read and agree to the above statement.

Signature *

Agree to Terms *

Agree

Client forms

New client form

Pet Information

Additional Pet Information

Permission to Use Photograph

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