If you would like to save time when you come for your first visit copy and paste to you word processing program and print out.
NEW BALTIMORE ANIMAL HOSPITALClient Information Form
Full Name: ____________________________
Spouse Name: _____________________________
Your driver’s license # _______________________________________________Spouse’s driver’s license #: ____________________________________________Street address: ______________________________________________________________
City: _______________________ Zip:________________Mailing address: ________________________________________________________________City: _______________________________Zip: _________________________Home phone #: _____________________________
Cell #: ______________________________Work : _________________________________
Spouse work #: ___________________________Email address: __________________________________________________________________Send you reminders by email? ___Don’t send you reminders by email? ___(Email information will not be shared outside of New Baltimore Animal Hospital)Local emergency contact: Relative or friend that can make treatment decisions for your pet if you cannot be contacted:Full name: _____________________________Relationship: ____________________Home phone #: _________________________ Cell/work _____________________--
Payment is due at time of service unless other arrangements are made in advance.
Preferred payment method: Cash __Check __AmEx __Discover __ MC ____Visa ____I clearly understand and agree that all services rendered to my pet are charged directly to me and that I am personally responsible for payment. If collection actions are initiated for any past due amounts, I agree to pay collection fees. I understand that a $6.00 per month billing charge will be added to any outstanding balance. In addition, interest at the rate of 24% per annum will be charged on any past due amounts. A $25.00 charge will be assessed for any returned checks. I understand that NBAH will endeavor its best efforts on my behalf, however, there are no guarantees associated with veterinary care. I further agree that any claim I may have against NBAH shall be limited to the payments I have made for the services rendered.Signature of client: _________________________ Date: _______________ Revised 1/5/2012
