Client Form for Wauconda Animal : Wauconda Animal Hospital

Primary Contact Name

Secondary Contact Name

Street Address

City

Zip

Client Status

New Client Existing Client

State

County

Lake McHenry Other

Being able to reach pet-owners quickly is important and often difficult; please provide the following contact informations.

What is the best number where we could reach you quickly?

Best Number

Contact Name

Cell

Home

Work

Second Best Number

Second Contact Name

Cell

Home

Work

We do not market any products by email; we may send reminders by email or important info related to health, hospital staff changes, ets.

I found out about your hospital from:

Friend/client/other

Website

Signage

Drive by

Appointment Date

Appointment Time

Patient (Pet) Information

Name

Feline

Canine

Breed

Sex

Female

Male

Spayed/Neutered

Date of Birth

Estimated Date of Birth

Patient Color and Markings

Does your pet have a microchip

Yes No

Microchip Number

Do you have Pet Health Insurance

Yes No

Name of Insurance Comany?

Financial Policy Summary:
We do not bill for services. Payment is due in full at the time that services are performed. We accept Cash, Check, Visa, Mastercard, Discover Amex and Carecredit payments.
There is a $35 fee on returned checks. We promote the use of Pet Health Insurance and are happy to keep, file, prepare, and send pre-signed claim forms in order to expedite your prompt reimbursement. Any information that w collect is private and for our use only. We do not extend credit. All open invoices are sent to collection after 30 days.

I have read, understand, and agree to the Financial Policy.

Signature

Date