County Line & Heritage Veterinary Hospital

CLIENT REGISTRATION

Save time at check-in. Please complete & click on "Submit".
Thank you for giving us the opportunity to care for your pet.

PLEASE CHECK ONE:

New Client

Current Client with new pet

Date & time of scheduled appointment

Please indicate at which Hospital you made your appointment:

County Line Veterinary Hospital

Heritage Veterinary Hospital

Owner Name

Address

City

State

Zip

Home Phone No.

Work Phone No.

Cell Phone No.

Co-owner/Spouse

Home Phone No.

Work Phone No.

Cell Phone No.

E-Mail Address for reminders, monthly newsletters & specials

How did you hear of our office?

Yellow Pages	Hospital Sign
Website	Referral

If by referral, whom may we thank?

PET INFORMATION

Name

Species

Breed

Birthday

Sex

Male

Neutered

Female

Spayed

Color/Markings

Vaccination History:

WE ACCEPT CASH, VISA/MASTERCARD/DISCOVER AND CHECKS. WE WILL ASK THAT YOU PROVIDE A DRIVERS LICENSE FOR CHECK WRITING PRIVILEGES. PLEASE PROVIDE INFORMATION ON YOUR CHECK, OR IN THE SPACE PROVIDED BELOW. THANK YOU.

Drivers Lincense No. for check writing privileges:

PLEASE READ GENERAL INFORMATION
& CLICK ON TODAY'S DATE BELOW BEFORE SUBMITTING FORM

1. I am 18 years of age or older and am the legal/authorized agent for this animal.
2. I accept financial responsibility for this animal.
3. Professional fees are to be paid in full at the time service is rendered. We do not offer any billing plans.
4. All unpaid balances are subject to service charges after 30 days. If payment is not received within 30 days, account is subject to be sent to collection agency. Should account balance become delinquent and is referred to collection agency, you will be responsible for fees of 33 1/3%, in addition to any service charges.
5. An estimate will be provided for treatment/surgical procedures. A deposit of 50% of the estimated total is required prior to admission for treatment/surgery.

Today's Date

Signature (to be completed at check-in)

By clicking "SUBMIT" below, you are acknowledging and accepting the above information.

* Indicates Response Required