Client Information Form

Owner's Name
First Name Last Name
Date of Birth
Spouse/Co-Owner's Name
First Name Last Name
Owner's Contact Information
Address
City State Zip
Cell Phone* Home Phone
Email*
Owner's Employment
Employer's Name*
Employer's Address*
City State Zip
Work Phone
Spouse's Employment
Spouse's Employer Name*
Spouse's Employer Address
City State Zip
Spouse's Work Phone


How were you referred to our hospital?
ReferralInternetDrove ByOther:
Regular Veterinarian?*


Pet Information
Pet Name
DOB Species
Gender Breed
Color Weight
Diet Previous Hospital


Agreement & Policies

To insure proper medical care for your pet(s), and for your convenience, Animal Medical and Surgical Center will enter your pets in our Computerized Recall System which will automatically mail you a reminder card at the appropriate time for all necessary vaccinations and exams. Please notify us of any address and/or phone changes.

FINANCIAL POLICY: Animal Medical and Surgical Center would like you to be aware that all fees are due when services are rendered. By signing below, I authorize Animal Medical & Surgical Center to process payment on my account using payment information provided by me. I understand that no guarantee can be made as to the results obtained from medical treatment. As legal owner or responsible agent of the above pet(s) I certify that I have read and agree to the above financial policy. I hereby assume financial responsibility for all services rendered.

Thank you for choosing Animal Medical and Surgical Center. Our primary mission is to deliver the best and most comprehensive veterinary care available for your pet. An important part of the mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options. Animal Medical and Surgical Center requires payment in full at the end of your pet's examination and/or at the time of discharge.

Payment Options:
- Cash, Visa®, MasterCard®, American Express® or Discover Card®

CareCredit
- Convenient Monthly Payment Plans allow you to begin treatment today and pay over time (subject to credit approval)
- Available for any treatment amount
- Can be used repeatedly, for your entire family, without having to reapply

Additional Policy Information:
Animal Medical and Surgical Center does not accept checks For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier. If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your pet. By signing below, you agree to the foregoing terms of payment

Accept*

Signature of Owner Date*