Partners For Pets – New Client Form

OWNER INFORMATION

Name

Street Address

State

Zip Code

City

Home Phone

Work Phone

Cell Phone

Driver's Licence Number & Issuing State

Social Security Number

Birth Date

Email

Which location would you like to go to?

Pike Rd

Montgomery

PATIENT’S INFORMATION

Pet's Name

Sex

Male

Female

Neutered Male

Spayed Female

Breed

Color

Date Birth

Microchipped? Y/N Microchip #

*PARTNERS FOR PETS SOMETIMES USES PATIENT PHOTOS FOR WEBSITE AND SOCIAL *PARTNERS FOR PETS SOMETIMES USES PATIENT PHOTOS FOR WEBSITE AND SOCIAL MEDIA PURPOSES. MEDIA PURPOSES.
*WE DO NOT BILL. PAYMENT IS EXPECTED AT THE TIME OF SERVICE. THERE WILL BE *WE DO NOT BILL. PAYMENT IS EXPECTED AT THE TIME OF SERVICE. THERE WILL BE AN INTEREST CHARGE OF 15% ON ALL OVERDUE BALANCES. AN INTEREST CHARGE OF 15% ON ALL OVERDUE BALANCES.

AGREEMENT TO PAY:

I, the undersigned, accept the fee charged as a legal and lawful debt and agree to pay said fee, including any/all collection agency fees, (33.33%), attorney fees and/or court costs, if such be necessary.

EXPRESS PRIOR CONSENT TO CONACT CONSUMER BY CELL PHONE:

You agree, in order for us to service your account or to collect monies you may owe, Partners for Pets and/or our agents may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending test messages or emails, using any emal address you provide us. Methods of contact may include using pre-recorded/artificial voice messages and/or use of automatic dialing device, as applicable. I/we have read this disclosure and agree that Partners for Pets, its employees and/or agents may contact me/us as described above.

Signature(Required)