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ITAH - New Client Form

New Client Form
Owner Information:
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How Did You Hear About Us?
Current Pet Information - Please fill out completely. (Males are neutered, females are spayed)
Species
Gender
Spayed/Neutered?
Microchipped?
Do you have another pet with you today?
Current Pet Information for Second Pet - Please fill out completely. (Males are neutered, females are spayed)
Species
Gender
Spayed/Neutered?
Microchipped?
Previous Veterinarian
(So we may obtain medical history)
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Payment Policy
PAYMENT IS DUE IN FULL AT TIME SERVICES ARE RENDERED

I understand that if I do not pay this account as agreed, the account is subject to costs of collection, attorney fees, and including interest (any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum). Returned check fee is $40. I understand that the hospital staff will provide an estimate of current and anticipated charges any time I request one. I am requesting that veterinary care be provided for pets presented by me or my agents. I understand that I am financially responsible for all services provided. For hospitalized cases, a deposit may be required in advance. By submitting this form I agree to the payment terms above. WE ACCEPT THE FOLLOWING: CASH, CHECK, MASTER CARD, VISA, DISCOVER, & AMERICAN EXPRESS. WE CAN ARRANGE FOR CareCredit, ASK OUR RECEPTIONIST FOR DETAILS.
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Signature of
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