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(615) 444-4422
New Client Welcome
Digital Empathy
2019-11-01T05:38:05+00:00
Welcome
Date
Owner
Spouse’s Name
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Home Telephone
Work Telephone
Email
Referred By
Cellphone
PROFESSIONAL FEES ARE TO BE PAID AT THE TIME THEY ARE RENDERED. PLEASE CHECK YOUR PREFERRED METHOD OF PAYMENT.
CASH
CHECK
CREDIT CARD
VISA
MASTERCARD
OTHER
If Other
Social Security
DL
Pet’s Name
Breed
Color
Birthdate
Sex
Male
Neutered
Female
Spayed
Any Medication? (If so please list:
What do you feed your pet?
Previous Medical Problems:
I fully understand and agree that all fees are due upon services rendered by Lebanon Animal Hospital. I fully understand and agree that any payment that is declined, cancelled and/or returned, shall be paid in full by me within twenty four (24) hours and I agree that I will be charged an additional $30.00 for any declined cancelled or returned payment.
I hereby understand and agree that should I fail to pay the amount due for services rendered for any reason whatsoever, I will be responsible for any and all reasonable attorney’s fees, expenses and court cost involved in the collection of any fees due Lebanon Animal Hospital.
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