New Client Form - Dickman Road Veterinary Clinic

Dickman Road Veterinary Clinic
NEW CLIENT INFORMATION SHEET
care for yo.y qet: So that we may be betrer able to meet your needs, please
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complete the following information. .the information
you provide^is for internal use ind creoit
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out.
*Information is neededfor check
cashing and controiled drug parposes.
Name:
Last Name
First Name
Middle Initial
Spouse's Name:
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Address: Street:
_Apt
HomeTelephone#( )
#
State:
City:
Cell#( )---
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Email:
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Place of Employment:
.t xtensl0n:
WorkTelephone#( )
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Spouse's Place of Employment:
Spouse's Work Telephone # (
Extension:
*Driver's License #
State oflssue:
ln case of emergency, nearest relative that does not live with you:
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Name
Address
lt:r
Ciwlstate/Zip
phone #
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our clinic's Jinunciul pofu iti/is that payment is expected at the time
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of service. Our puytrcent
+
+
,i!
*
ns are
as
follows:
Cash
Checks
Major credit cards (Vls4iMi3te.iira, Discover)
Care Credit (can
!e aylied for at the time of service, approval only takes a couple of minutes)
There is a 0.5837.0'service charge per month (annual percentage rate of |Yo)on balances over 30 days past due and a billing charge of
$1 eachmontfu'tb.covgr.the cp,st of mailing your statement. You agree to reimburse us the fees of any collection agency, *6"tr ruy
be based on a pereqrltage.$ a maximum of 30oh of the debt as well as a fee of $8.25, and all costs, and expenses, inctuOing ."asonatl"
attorneys' fees,
in such collection efforts. If any check given to us as payment on your account is returned
1ve fhgyl
reason.by your fina4cial institution, there will be a $25 fee added to your account.
*puid
for any
I understand that I must provide all the information requested and that you may verifi and exchange information on me,) including
t.qrr.tiiiie,,lgports from iredit reporting agencies and bank references fbr instailment payment appioval.
By signing this form, I am saying that I have read and understand the above payment options and service
charges.
Signature:
Date:
LIST OF PETS
#l
Name:
one): cANINE (Dog), FELINE (cat), REPTILE, AVIAN, orHER
sex (Please circle one): FEMALE, FEMALE spAyED, MALE,
MALE NEUTERED
Species (Please circle
Breed:
Color:
Date of Birth:
Age:
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#2
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Name:
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one): GANINE (Dog), FELINE (cat), REPTILE, *VlaN,r,,grHEn
Sex (Please circle one): FEMALE, FEMALE spAyED, MALE, \4ALE NEUfERED
Species (Please circle
Breed:
Date of Birth:
Aee:
-l:1r..
#3
Name:
one): CANINE (Dog), FELINE (cat), REPTILE, AVIAN, orHER
Sex (Please circle one): FEMALE, FEMALE Spavpb; MALE, MALE NEUTERED
Species (Please circle
Breed:
Color:
Date of Birth:
#4
Age:
Name:
Species (Please circle
one): GANINE (Dog), FELINE (Cat), REPTILE, AVIAN, 9THER
Sex (Please circle..one):
FEMALE, FEMALE SPAYED, MALE, MALE NEUTERED
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Breed:
color:
Date of Birth:
#5
Name: :.,
Age:
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species (Please circle
one): GANINE (Dog), FELINE (cat), REPTILE, AVIAN, orHER
Sex (Please circle one):
FEMALE, FEMALE SPAYED, MALE, MALE NEUTERED
.:,..
Bieed:
Date of Birth:
Color:
Age: