Berryhill Animal Hospital Patient/Client Information Form

Berryhill Animal Hospital

Client Form

Berryhill Animal Hospital
Patient/Client Information

* Required Fields

Owner's Name^*
Spouse/Other
Address^*
City^*	State^* Zip^*
Home Phone^*	Cell
Work Phone	Ext
E-Mail^*
Social Security #

Employer's Name
Employer's Address
City	State Zip

In case of EMERGENCY, please call at telephone number
Please check how you would like your vaccination reminder sent:
Mail E-mail

How did you hear about our hospital?
Individual, someone we may thank?
Yellow Pages
Other

We will gladly prepare a written estimate if you desire. Please ask the receptionist or doctor. PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. If you pay by check or credit card, please complete the following:

Card Type: Credit Card Number: Exp Date:
Check Drivers License:Stave/Prov Number

Please use text area below to provide other information we might
need to know about your pet's and their special needs and/or requests:

Payment Policy: In an effort to maintain our high standards of care, we DO NOT BILL for services rendered. I agree to pay for all services and medications as they are rendered. I also understand that any check that I tender for payment that is returned for any reason will cause a $30.00 returned check fee charged to my account. I further understand that if my account becomes overdue for any reason I agree to pay interest on past due balances at the rate of 18% annually. I also understand that if my account becomes delinquent it will be turned over to an attorney or collection agency. I agree to pay the cost of collection, including attorney fees, of no less than $75.00 and I expressly agree that this is a reasonable attorney fee for collection of my account.
I agree to the Payment Policy.
Boarding Release: Should a boarding animal become ill, or be in the need of any medications, we reserve the right to treat the animal at the owner's expense. Charges will be made payable to Berryhill Animal Hospital at the time of the animal's discharge. Should written proof of vaccinations not be provided and/or vaccinations cannot be verified for any reason, we reserve the right to vaccinate the animal for all required vaccinations at the owner's expense.
I agree to the Boarding Release.
If the information above is correct, then simply click "submit".
To start over, click "reset".