Owner's Name
*
Phone
*
Format: (000) 000-0000.
Cell
*
Spouse's Name & Phone / Cell
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
example@example.com
Owners Date of Birth
*
Driver's License # State Exp,
*
How did you hear about our clinic?
Pet #1
Name
Gender
Male
Female
Spayed / Neutered
Yes
No
Kind of Pet
Dog
Cat
Rabbit
Ferret
Reptile
Rodent
Other
Breed
Color
Species (if exotic)
Age
Microchip Number
Pet #2
Name
Gender
Male
Female
Spayed / Neutered
Yes
No
Kind of Pet
Dog
Cat
Rabbit
Ferret
Reptile
Rodent
Other
Breed
Color
Species (if exotic)
Age
Microchip Number
Pet #3
Name
Gender
Male
Female
Spayed / Neutered
Yes
No
Kind of Pet
Dog
Cat
Rabbit
Ferret
Reptile
Rodent
Other
Breed
Color
Species (if exotic)
Age
Microchip Number
** Payment is Expected at the Time Services are Rendered ** We accept cash, in-state checks, Visa, MasterCard, and Care Credit.
By checking this field, I the undersigned, owner or authorized agent of the above admitted patient, here by authorize the doctors of Country Club Veterinary Clinic to administer such treatment as is necessary and to perform procedures therapeutically and/or diagnostically. I further understand that no guarantee of successful treatment is made. I also assume financial responsibility for all charges incurred, and agree to pay all such charges at the time of release. I understand that unpaid balances over 30 days are subject to a monthly 1.5% (18% APY) finance charge. Any balance that I leave unpaid will be forwarded to our collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges. There will be a $35 fee charged for any check that is returned. At your request we will gladly discuss cost of services and/or prepare a written estimate of recommended procedures/treatments. Deposits may be required for pets being admitted into the hospital.
*
Yes
Signature
*
Date
*
-
Month
-
Day
Year
Date
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