Client Welcome Form





Your First Name:
Your Last Name:
Spouse Name:
Email:
Street Address:
City:
State:
Zip:
Cell Phone:
Home Phone:
Spouse Cell:
Work:
Preferred Method of Contact:
Emergency Contact’s Name:
Relationship:
Phone:
Please list number of pets you own:
Dogs(#)
Cats(#)
Birds(#)
Other:
Pet Insurance?
Company Name:
Do you have Care Credit?
How did you first learn of our clinic?
Other:
Referred by friend or family member?
Veterinarian ( Referring Vet’s Name and Phone)

I understand that all fees are to be paid at the time services are rendered.

Authorization for Professional Services

I hereby authorize Animal Health Care P.C. to perform such diagnostics, therapeutic and surgical procedures as are necessary and advisable for
treatment and maintenance of my pet’s health and well-being. The nature of such service has been described to me to my satisfaction, and while I
expect all procedures to be done to the best abilities of the professional staff, I realize that no guarantee or warranty can ethically or professionally be
made regarding the results or cure. I agree to pay all charges incurred at the time of release of my pet, including reasonable attorney’s fees and cost of
collection in the event of default. I further understand that if payment becomes 30 days past due, delinquency charges at the lesser of the annual rate of
18%, or the maximum allowance rate, will be due on delinquent amounts from whenthe payment was due. I also authorize the hospital director and his
staff, to provide veterinary services as requested or in emergency circumstances to follow through with such procedures as are necessary for the well -
beingof my pet on a continuing basis until further advised in writing

Date:
Signature:

Check to confirm submission.

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