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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?
Is this pet new to your family? (If yes, please provide us with their records prior to the appointment. We can call you to obtain records or you can take pictures of them and email them to us. If you have them in digital format, please email them to us at: welcome@indiantreeanimalhospital.com.)
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?
Do you have another pet with you today?
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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