Emergency Service Agreement

Your Name

First

Last

Spouse

First

Last

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Home Phone

Cellphone

Work Phone

Employer(yours)

Spouse

Driver’s License#

E-mail address

If a new client, how did you become aware of our hospital?

Whom may we thank?

Pet/Patients information: ( if not a current patient within the last year)

Name

Color

Species

Prior Surgery/Illness

Breed

Birthday/Age

Sex

Allergies/On Meds?

Fees: All fees are due upon completion of visit.

Methods of payment: Cash, Check and Major Credit Cards

Payment in full is required when the patient leaves the hospital unless other payment arrangements have been made with our business office, prior to treatment.
Accounts older than 90 days will receive no further services until paid in full
Client agrees to pay any and all reasonable attorney’s cost and fees, if any incurred to collection of clients’ account.
If hospitalization/over night stay is required, a 50% deposit will be required and may be paid with cash, check or credit card.

Signature

Sign above

Date

----Credit Card Use----

Credit Card Name

Credit Card #

Exp. Date

Credit Card Auth. Signature

Sign above

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