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Animal Eye Care Center
Call (301) 990-6373 to schedule an appointment.
Animal Eye Care Center
Call (301) 990-6373 to schedule an appointment.
Animal Eye Care Center
Call (301) 990-6373 to schedule an appointment.
Animal Eye Care Center
Call (301) 990-6373 to schedule an appointment.
Animal Eye Care Center
Call (301) 990-6373 to schedule an appointment.
Animal Eye Care Center
Call (301) 990-6373 to schedule an appointment.
Animal Eye Care Center
Call (301) 990-6373 to schedule an appointment.
Animal Eye Care Center
Call (301) 990-6373 to schedule an appointment.
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WELCOME to the ANIMAL EYE CARE CENTER, LLC
‘A Site for Sore Eyes’
Registration Document
Click here to print hard copy to bring to the office or fill out the online form on this page.
Client Information
First Name
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Last Name
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Phone
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Email
Home Address
City/State
Zip Code
Place of Employment
Phone
Spouse / Co-owner
Spouse / Co-owner’s Employment
Phone
Pet's Information
Pet’s Name
Species
Sex
Male
Female
Neutered / Spayed?
Yes
No
Breed of Animal
Date of Birth
Is your pet allergic to any medication? If so, what?
Can your pet be aggressive?
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No
Sometimes
Veterinary Information
Name of your veterinarian
Hospital Name and Phone Number
How did you hear about us?
I Agree to Terms & Conditions
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Agree
Terms & Conditions
ASSUME FULL FINANCIAL RESPONSIBILITY FOR ALL CHARGES INCURRED TO THIS PATIENT. PAYMENT FOR SERVICES IS DUE IN ITS ENTIRETY AT THE TIME THAT SERVICES ARE PROVIDED. IF A CHECK IS RETURNED, THE OWNER AGREES TO PAY A $25.00 PROCESSING FEE. IF FOR ANY REASON THE CHARGES ARE NOT PAID IN FULL AT THE TIME OF THE PET'S RELEASE, I WILL BE RESPONSIBLE NOT ONLY FOR THE BALANCE DUE, BUT FOR A $10.00 MONTHLY BILLING FEE. AS WELL AS FOR ANY COLLECTION AND/OR REASONABLE ATTORNEY FEES THAT ARE INCURRED IN THE ATTEMPT TO COLLECT THIS DEBT. ** IF YOU DO NOT SHOW AND DO NOT CALL TO CANCEL/RESCHEDULE AN APPOINTMENT. YOU WILL BE REQUIRED TO PRE-PAY FOR THE NEXT EXAM. REFUNDABLE ONLY IF EXAM IS CANCELLED/RESCHEDULED AT LEAST 24HOURS BEFORE APPOINTMENT TIME.
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