ITAH - Client Information & Financial Agreement

Client Information & Financial Agreement

Owner Information:

Name/Owner

Co-Owner

Date Completed This question requires a valid date format of MM/DD/YYYY.

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Address

City

State

Zip Code

Phone # This question requires a valid number format.

Cell # This question requires a valid number format.

Work # This question requires a valid number format.

Co-Owner #: This question requires a valid number format.

Employer:

Email Address (We use this to remind you of vaccinations due and send you email-only ITAH promotions.) This question requires a valid email address.

How Did You Hear About Us?

Please enter an 'other' value for this selection.
Please enter an 'other' value for this selection.
Please enter an 'other' value for this selection.

Current Pet Information - Please fill out completely. (Males are neutered, females are spayed)

Current Pet Information for Second Pet - Please fill out completely. (Males are neutered, females are spayed)

Which pet insurance company is your pet insured under?
(So we may submit your claims for you)

Previous Veterinarian
(So we may obtain medical history)

Name

Phone # This question requires a valid number format.

I agree to provide Indian Tree Animal Hospital with records or the previous clinics name prior to my appointment.

Payment Policy

PAYMENT IS DUE IN FULL AT TIME SERVICES ARE RENDERED

I understand that if I do not pay this account as agreed, the account is subject to costs of collection, attorney fees, and including interest (any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum). Returned check fee is $40. I understand that the hospital staff will provide an estimate of current and anticipated charges any time I request one. I am requesting that veterinary care be provided for pets presented by me or my agents. I understand that I am financially responsible for all services provided. For hospitalized cases, a deposit may be required in advance. By submitting this form I agree to the payment terms above. WE ACCEPT THE FOLLOWING: CASH, CHECK, MASTER CARD, VISA, DISCOVER, & AMERICAN EXPRESS. WE CAN ARRANGE FOR CareCredit, ASK OUR RECEPTIONIST FOR DETAILS.

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Signature of

Date This question requires a valid date format of MM/DD/YYYY.

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