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University Veterinary Hospital New Client Information
Owner: ___________________________Spouse/Co-owner: _____________________________
Address: __________________________________City: State: Zip: __________
Home Phone: __________________Cell : ____________________Work : ______________________
Co-owner Phone: ________________Cell : __________________Work : _______________________
Occupation: _______________________________Employer: ________________________________
Co-owner Occupation: _________________________Employer: _________________________
Driver’s License: ________________________Social Security ________________
Required for check writing Required for check writing
Emergency Contact: _______________ Phone: ____________________________
How did you become aware of our clinic? □ Drove By Yellow Pages: □ Big Book □ Little Book □ Radio □ Referral □ New Neighbor Mailer □ Web Search □ City Weekly □ SLAC Playbill □ Web Page □ Animal Services □ Other
** If another client referred you, whom may we thank?
** If other, please describe ______________________________________
Do you have health insurance for your pets? Y / N Are you interested in learning about insurance? Y / N
Pets: Name Dog / Cat Age Breed _______________ Color Female Spayed Male Neutered
Name Dog / Cat Age Breed _______________ Color Female Spayed Male Neutered
Name Dog / Cat Age Breed ________________ Color Female Spayed Male Neutered
Which veterinary hospital last vaccinated your pet(s)? May we contact them? □ Yes □ No
Hospital/Doctor Name: _______________City, State: ___________________ Telephone Number: _______
Would you be interested in being contacted via e-mail for appointment reminders, announcements or other pet related topics? □ Yes □ No
If yes, e-mail address: _______________________________________________________________
Do we have your permission to release your pet(s) vaccination history to boarding and grooming facilities you wish to use?□ Yes □ No
I certify that I am the owner of the animals listed above. To the best of my knowledge, the above information is correct. I understand that fees are due and payable at the time services are rendered, and I agree to pay for those services. This debt was incurred as a result of treatment and care requested and authorized by me. I understand and agree that I will pay the maximum collection costs, in addition to interest in the amount of 24% annually, court costs, and reasonable attorney fees associated with the collection of any overdue or unpaid balance.
Signature: Date: ______________________________
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