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CLIENT REGISTRATION FORM

CLIENT INFORMATION

PET INFORMATION

VETERINARY INFORMATION

Terms and Conditions

I 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.

* A $50 DEPOSIT IS REQUIRED TO SCHEDULE AN APPOINTMENT WHICH IS REFUNDED PROVIDED YOU RESCHEDULE OR CANCEL YOUR APPOINTMENT AT LEAST 24 HOURS BEFORE APPOINTMENT TIME.

** IF YOU DO NOT SHOW AND DO NOT CALL TO CANCEL/RESCHEDULE AN APPOINTMENT YOUR $50 DEPOSIT IS FORFEITED AND YOU WILL BE REQUIRED TO PRE-PAY FOR THE NEXT EXAM. REFUNDABLE ONLY IF EXAM IS CANCELLED/RESCHEDULED AT LEAST 24 HOURS BEFORE APPOINTMENT TIME.

Types of payment accepted:        Visa        Mastercard        Discover        Check        Cash

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*INDICATES A REQUIRED FIELD

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