New Client Registration Form

Date

Owner's Information

Owner's Name*

Spouse/Other's Name

Street Address*

City*

Zip*

Home Phone*

Work Phone Number

Cell Phone*

Spouse Cell Phone

Email*

Pet's Information

Pet's Name*

Date of Birth/Age*

Pet's Species*

Pet's Breed*

Pet's Color*

Pet's Gender*

Spayed/Neutered?*

How did you hear about us?*

If by referral, then who may we thank?

I assume responsibility for all charges incurred in the care and treatment of this animal. I also understand that these charges will be paid at the time of service or release, and a deposit may be required for some medical and/or surgical procedures. The undersigned agrees to pay a finance charge of 1.5% per month on any unpaid balance. In addition, I further agree to the cost of collection, postage, and a reasonable attorney’s fee in the event said account is tuned over for collection.

Print Name of Owner or Responsible Party*

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