Owner's Name: (required)
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Co-owner:
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Primary Cell Phone: (required)
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Co-owner's Cell Phone:
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What day and time is your scheduled appointment? (You must first call our office to schedule your appointment) (required)
:
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Home Phone Number:
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E-Mail: (required)
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Preferred Method of Patient Vaccine Reminders? Select one: (required)
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Owner's Place of Employment: (required)
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Work Number: (required)
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Co-owner's Place of Employment:
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Work Number:
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Additional Person(s) Authorized to Use My Account:
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How did you become aware of our hospital? (required)
Internet
Friend/Relative (Someone whom we may thank?)
Sign/Location
Previous Client
Other
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Previous Veterinarian?
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If so, please list the reason for leaving:
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We will gladly prepare a written estimate of service fees if you desire. Professional fees are due at the time services are rendered. |
DUE TO STATE LAW, ALL DOGS & CATS MUST BE CURRENTLY VACCINATED FOR RABIES:
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All dogs & cats that are hospitalized and not current on vaccines will be kept in isolation at an additional cost of $48.50 per day.
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I hereby agree to pay for services rendered at the time my pet is discharged from the hospital or the service is provided. I agree to pay for the reasonable costs of collection and attorney fee in the even that collections efforts become necessary.
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Also, I acknowledge interest will be added at a rate of 1 1/2% per month or the maximum rate then allowed by law.
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Gladly accepting Cash, Mastercard, Visa, Discover, American Express, and Care Credit
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Please sign this agreement by typing out your first and last name. (required)
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Date (mm/dd/yyyy): (required)
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Is your pet a Dog or a Cat? (required)
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If your pet is a cat is it:
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If a dog, what breed is your dog?
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Age of Pet? (required)
:
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Color of Pet? (required)
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Is your pet spayed or neutered? (required)
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PLEASE EMAIL YOUR PET'S HISTORY TO NAHCLIENTRECORDS@GMAIL.COM 24 HOURS PRIOR TO YOUR APPOINTMENT! Thank you! |
What is the reason for your visit? (required)
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If your pet is being seen for something other then vaccines, please list all the symptoms your pet is having:
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