PATIENT/CLIENT INFORMATION Thank you for giving us the opportunity to care for your pet. We truly value the human-animal bond and strive to treat your pets just as we would our own. Please take a moment to complete both sides of this information sheet. Date:_____________________________ Owner #1 Name____________________________________________________________________________ Home Phone____________________________________ Fax #______________________________________ Mailing Address____________________________________________________________________________ City________________________________________________State______________Zip_________________ Email Address____________________________________________ TDL#____________________________ Mobile Phone___________________________________ Work Phone________________________________ Owner #2 Name____________________________________________________________________________ Email Address____________________________________________ TDL#____________________________ Mobile Phone___________________________________ Work Phone________________________________ In case of EMERGENCY, alternate contact name:_________________________________________________ Phone #(s)_________________________________________________________________________________ How did you first hear of our hospital? o Individual; someone we may thank?_______________________________________________________ o Yellow Pages o Website (www.tomballanimalhospital.com) o Google o Facebook o Hospital Sign o Other__________________________________________________ To prevent the spread of infectious diseases and parasites, any patients entering our kennel ward, must be current on all vaccines and free of internal and external parasites. I authorize the veterinarian to provide vaccines and parasite treatment as needed for my pet. We will gladly prepare a written estimate if you desire. Please ask the receptionist, technician or doctor. Professional fees are due at the time services are rendered. We accept cash, check (via Telecheck), AmEx, Discover, M/C, and VISA. We also accept Care Credit if you desire a payment plan option (please see the receptionist for more information). Should it become necessary to forward any debt incurred with Tomball Animal Hospital, P.C., I agree to be responsible for any and all collection costs, attorney fees, and/or court costs. Any unpaid balances will be subject to a finance charge of 1.5% per month, (18% APR). By signing below, I am stating the above information provided is true and correct, and I have read and understand this sheet in its entirety. _________________________________________________ Signature of Owner

_______________________________ Date

Please provide the pet’s information on the second sheet (for New Patient)

New Client Information Sheet.pdf

receptionist for more information). Should it become necessary to forward any debt incurred with Tomball. Animal Hospital, P.C., I agree to be responsible for any and all collection costs, attorney fees, and/or court. costs. Any unpaid balances will be subject to a finance charge of 1.5% per month, (18% APR). By signing ...

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