Client Information Form

Owner

Name of co-owner/spouse

Email Address

Primary Number

Secondary Number

Other Number

Mailing Address

Who referred you to us?

Can we post photos of your pet(s) on our social media site(s)?

Yes

Do you have medical insurance for your pet?

Yes

Are you interested in pet insurance?

Yes

Pets Information

Are your pets listed under any other names other than what you have indicated on the first page? *

List any other veterinary practices you have been to so we may obtain medical records. *

Any other special notes we might need to know:

Please note that full payment is due at the time of services rendered. In the event that there is a balance left on your account a monthly interest charge of 1.3% will be applied. Understand that in the event we need to engage a recovery agency you agree to reimburse us the fees of said agency, which may be based on a percentage at a maximum of 33% of the debt, and all costs, and expenses, including reasonable attorneys’ fees (currently $125, in addition, the to the 33%) incurred in such collection efforts.

Signature *

Date *

Phone