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.