New Client Form - Richfield Area Pet Clinic, LLC

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Daytime Phone*

Phone number*

Evening Phone*

Phone number*

Pets's Name*

Age: Years, Months

Type of Pet*

Breed

Sex*

Male
Female

Neutered/Spayed

Neutered
Spayed

Are your pets' vaccines current?

Do you have pets' medical records?

Medical records at another veterinary Practice?

Yes
No

Name of Former Veterinary Practice

May we request a transfer of records?

Yes
No

Would you like us to call you for your appointment

Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Richfield Area Pet Clinic, LLC and that charges are due and payable at the time of service. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Richfield Area Pet Clinic, LLC's collection agency and/or attorneys, and I will be responsible for all associated collection costs, in addition to the unpaid balance and finance charges.

I have read this statement and*

I Agree
I Disagree

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