SPRING PARK ANIMAL HOSPITAL NEW PATIENT FORM

                                                                                                            DATE   

NAME           SOCIAL SECURITY NO   

SPOUSE            SOCIAL SECURITY NO       

ADDRESS          HOME PHONE   

IF P.O. BOX, PLEASE GIVE PHYSICAL ADDRESS   

CITY       STATE              ZIP   

EMAIL ADDRESS

EMPLOYER         POSITION        WORK PHONE   

SPOUSE'S EMPLOYER    POSITION  WORK PHONE 

The above client requests the Staff of Spring Park Animal Hospital to perform such medical, dental, or surgical treatment as the Staff deems necessary or advisable for the well-being of patients presented.  Client agrees to pick-up patient from Spring Park Animal Hospital within 5-days of being notified that patient is ready for discharge and to pay actual charges in full at time of discharge.  Client agrees to pay interest at the rate of 1% per month on any balance not paid within 30-days.  Client also agrees to pay a billing charge of $4.00 per month on any balance not paid within 30-days.  Client further agrees to pay attorney fees, court costs, and other expenses of collection should the account become delinquent.

 

CLIENT'S SIGNATURE   

PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.

WE ACCEPT CASH, CHECK OR CREDIT CARD.

REASON FOR CHOOSING OUR CLINIC:

Location            Yellow Pages (Big Book)            Yellow Pages (Small Book)            Area Newcomers Service   

Clinic Brochure            Internet Search Engine            Website Referral            Other   

WHOM MAY WE THANK FOR REFERRING YOU?   

IF VISITING THE AREA, YOUR LOCAL PHONE NUMBER       

PATIENT INFORMATION

THANK YOU FOR CHOOSING US TO HELP KEEP YOUR PET HEALTHY!