Client Information Form

Please Complete the Entire Form




*Client Information






*Telephone/ Home

Telephone/ Work

Telephone/ Cell



Employer Address

Spouse's Employer

Spouse's Work Phone

Drivers License (required if paying by check)

Pet Information
*Type of Pet (Dog, Cat, Bird, ect)

*Name of Pet




*Is the pet neutered? (Y/N)

Pet's Birthdate

Please list any existing medical problems your pet has

*Date last vaccinated

Place last vaccinated

Is your pet microchipped? (Y/N)

If yes, microchip number

How did you learn about Nile's Animal Hospital?

All fees are due and payable on the day of treatment. A deposit for the first day of treatment is required on all hospitalized pets. Any outstanding bill will receive a monthly 1.5 % finance charge and a $3.65 billing charge at time of billing.
I understand I am fully responsible for all charges involved with my pet and in case of nonpayment I will be legally responsible to pay Niles Animal Hospital:
The total medical bill, all finance and billing charges, a $ 25.00 collection fee, and all attorney fees and court costs involved with the case.
As the owner of this pet, I authorize treatment and payment in full including, if necessary, the above charges associated with the collection of the bill. I understand I may pay with Cash, Check, Visa, Mastercard or Discover.