RHVH - Client Information Sheet

Client Information Sheet
Thank you for giving us the opportunity to care for your pet.
Please help us to better meet your needs by taking a moment to complete this information sheet.

Client Information

Date

Owner's Name

Spouse/Co-Owner:

Address

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Email Address

In case of an EMERGENCY, please call:

at Telephone #

2. Does your pet have an Instagram page? List their username here (ex. @):

Payment:
We accept cash, checks, all major credit cards, and CareCredit for your convenience. We are in compliance with the “Red Flags” rule passed by the FTC to ensure your identity and privacy are secure.

If you would like to leave your credit card on file as a convenience for future use, please initial here and inform the receptionist.

I understand that I may receive a written fee estimate if I request one and that a final fee will be based on actual services rendered. Payment is due as services are rendered. For hospitalized cases, a deposit is required in advance. The balance is due upon discharge from the hospital. In the event payment is not made at the time of service, it is our policy to apply a service charge to accounts with a balance over 30 days old. All returned checks will incur a charge of $35.00. In the event the account is referred for collection, balances owed will be subject to additional annual interest charges of 16%.

Clear

Signature of