Owner

• First name*
• Last name*
• Address line 1*
• Address line 2
• City*
• StateNYNJCTMA
• Zip
• Home phone #*
• Mobile phone #
• E-mail
• Date of birth
• Spouse, if married
• Employer
• Employer's address
• Work phone #

Pet

• Pet's name*
• Breed*
• Pet's date of birth
• Color(s)*
• Species*---DogCat
• Gender*---FemaleMaleNot sure
• Spay / Neutered?---YesNo
• If spayed/neutered, date?
• Tattoo/microchip #
• Allergies (if known)

Payment in full is requested at time of service or upon release of the animal from the hospital, unless special credit arrangements have been made in advance. Our credit accounts are handled solely through Visa and Master card. You may pay by cash or check if you prefer. In order to avoid misunderstanding, we urge that all fees be discussed with the doctor before services are performed. All accounts over 30 days are subject to a service charge of 1.5% per month on unpaid balance. A total of 18% per annum. Any accounts unpaid over 90 days will be sent to a collection agency and will be subject to a processing fee of $10.00.

I have read the above and agree to the terms listed.

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