Patient/Client Information Form - Cascade Veterinary Clinic

CLIENT INFORMATION

Owner's Name

Spouse/Other

Mailing Address

Street Address City State / Province / Region ZIP / Postal Code

Physical Address

Street Address City State / Province / Region ZIP / Postal Code

Home Phone

Work Phone

Employer's Name and Address

At what time is it best to call about your pet

and at what phone

In case of EMERGENCY, call

and at what phone

Name of Previous/Current Veterinarian:

May we contact them and request a copy of your pet’s records?

Yes

FINANCIAL INFORMATION

We will gladly prepare a written estimate if you so desire. Please ask a receptionist or doctor. Professional fees are due at time services are rendered. If you wish to pay by check or credit card, please complete the following:

Preferred Method of Payment:

Check

Credit Card

Bank Name

Driver’s License

Owner’s Social Security

Spouse/Other SSN

HOW DID YOU HEAR ABOUT OUR PRACTICE?

How did you hear of our hospital?

Individual, someone we may thank?

Hospital sign?

Another hospital? (Please specify.)

Yellow pages or another telephone directory?

Other? (Please specify.

Name

Another Hospital

Other

Would you like to be on our mailing list?

Yes

(If so, you will receive timely reminders when your pet’s vaccinations, examinations, etc., are due.)

To help prevent the spread of infectious diseases, ALL hospitalized and boarded animals must be current on all vaccinations.

I (OWNER) understand every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care and handling. I hereby authorize this hospital to receive, prescribe for, treat or perform surgery upon my pet(s). Furthermore, I agree to pay fees for services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated. I agree to pay for the reasonable costs of collection in the event that collection efforts become necessary.

In the event that I become delinquent and payment is not made on amounts owing under the terms of this agreement, and the balance is placed with a licensed collection agency, I agrees to pay the fees of the collection agency, which amount is therefore agreed to be 50% of the outstanding balance at the time the account is placed for collections. The 50% collection agency fee will be calculated and added at the time the account is placed into collections.

Signature

Date