New Client/Owner Form NameSpouseMailing Address AND Street AddressCityZip CodeMAIN CONTACT NUMBERWork/Home/CellIs it OK to contact you via textYesNoNumber to text:Email address Would you like to receive reminders for annual physicals, vaccines, etc. byMailEmailMail and EmailWould you like to receive our informational newsletter by email?YesNoPlace of employmentChildren-if still at home (names/ages)Driver License Number (State)(If writing check)Preferred method of payment cash Check credit card Care Credit Do you have pet insurance?YesNoCompany?Are you eligible for senior discount? (over age 65)YesNoHow did you hear about us? Please help us to know the most effective way to reach out to new clients. If a friend who is a client referred you, they will receive a coupon for $20 off services at their next visit.Phone bookNewspaperFriendSaw signInternet, what search words if you rememberOtherPlease SpecifyThe following statements must be signed in acknowledgment of hospital policies. Full payment is expected at the time of service unless prior written arrangements with the doctor have been made. Any returned checks are subject to a service charge of $35 and any additional processing fees. There is a $5.00 per month billing charge and 1.5% accrued finance charge for any unpaid balances over 30 days. Any accounts overdue by more than 60 days will be DOUBLED and turned over to a collection agency or pursued legally. Any costs involved with collection of an overdue account, together with attorney’s fees, will be added to the overdue balance.
