New Client FormSeymour, IN

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a cat sitting in the room

New Client Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

CLIENT INFORMATION

ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED

*If this is a concern please notify a hospital staff member prior to treatment so that we may establish the most cost-effective treatment plan.

PATIENT INFORMATION

Pet #1

Pet #2

Pet #3

I assume responsibility for all charges incurred in the care of the above animal(s). I understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment or hospitalization. I agree that in case of non-payment, a 1.5% per month interest charge will be assessed on accounts not paid within 30 days. In addition, if referral to an outside attorney or collection agency becomes necessary, I will pay a collection fee up to 50% of the balance. This agreement is enforced indefinitely from this date.
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