Client Information Form Please Complete the Entire Form *Client Information *Client *Address *City *State *Zip *Telephone/ Home Telephone/ Work Telephone/ Cell *Email Employer 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 *Breed *Color *Sex *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.