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Please Complete the Entire Form

 

 

 


*Client Information
*Client
*Address
*City
*State
*Zip
*Telephone/ Home
Telephone/ Work
Telephone/ Cell
*Email
Employer
Employer Address
Spouse's Employer
Spouse's Work Phone
Drivers License (required if paying by check)

Pet Information
*Type of Pet (Dog, Cat, Bird, ect)
*Name of Pet
*Breed
*Color
*Sex
*Is the pet neutered? (Y/N)
Pet's Birthdate
Please list any existing medical problems your pet has
*Date last vaccinated
Place last vaccinated
Is your pet microchipped? (Y/N)
If yes, microchip number
How did you learn about Nile's Animal Hospital?

All fees are due and payable on the day of treatment. A deposit for the first day of treatment is required on all hospitalized pets. Any outstanding bill will receive a monthly 1.5 % finance charge and a $3.65 billing charge at time of billing.

I understand I am fully responsible for all charges involved with my pet and in case of nonpayment I will be legally responsible to pay Niles Animal Hospital:

The total medical bill, all finance and billing charges, a $ 25.00 collection fee, and all attorney fees and court costs involved with the case.

As the owner of this pet, I authorize treatment and payment in full including, if necessary, the above charges associated with the collection of the bill. I understand I may pay with Cash, Check, Visa, Mastercard or Discover.
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