CLIENT REGISTRATION FORM

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CLIENT INFORMATION

First Name

Last Name

Phone Number

Home Address

City

State

Zip Code

Place of Employment

Phone

Spouse/Co-owner

Spouse/Co-owner Place of Employment

Phone

PET INFORMATION

Pet's Name

Species

Sex

Neutered / Spayed?

Breed

Date of Birth

Is your pet allergic to any medication? If so, what?

VETERINARY INFORMATION

Name of your Veterinarian

Hospital Name

Phone Number

Why did you choose the Animal Eye Care Center?

I agree to the terms & conditions*

Terms and Conditions

I ASSUME FULL FINANCIAL RESPONSIBILITY FOR ALL CHARGES INCURRED TO THIS PATIENT. PAYMENT FOR SERVICES IS DUE IN ITS ENTIRETY AT THE TIME THAT SERVICES ARE PROVIDED. IF A CHECK IS RETURNED, THE OWNER AGREES TO PAY A $25.00 PROCESSING FEE. IF FOR ANY REASON THE CHARGES ARE NOT PAID IN FULL AT THE TIME OF THE PET’S RELEASE, I WILL BE RESPONSIBLE NOT ONLY FOR THE BALANCE DUE, BUT FOR A $10.00 MONTHLY BILLING FEE, AS WELL AS FOR ANY COLLECTION AND/OR REASONABLE ATTORNEY FEES THAT ARE INCURRED IN THE ATTEMPT TO COLLECT THIS DEBT.

* A $50 DEPOSIT IS REQUIRED TO SCHEDULE AN APPOINTMENT WHICH IS REFUNDED PROVIDED YOU RESCHEDULE OR CANCEL YOUR APPOINTMENT AT LEAST 24 HOURS BEFORE APPOINTMENT TIME.

** IF YOU DO NOT SHOW AND DO NOT CALL TO CANCEL/RESCHEDULE AN APPOINTMENT YOUR $50 DEPOSIT IS FORFEITED AND YOU WILL BE REQUIRED TO PRE-PAY FOR THE NEXT EXAM. REFUNDABLE ONLY IF EXAM IS CANCELLED/RESCHEDULED AT LEAST 24 HOURS BEFORE APPOINTMENT TIME.

Types of payment accepted: Visa Mastercard Discover Check Cash

Signature

Date

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*INDICATES A REQUIRED FIELD