New Client Info Sheet

Kutztown Animal Hospital welcomes you! In order to get acquainted please complete the following…

Your Name/Your Spouse’s Name__________________________________________________

Other Interested Party?__________________________________________________________

Address_________________________ City_______________ State___________ Zip________

Home Phone_________________ Work Phone_________________ Cell__________________

Email Address________________________________________________________________

Driver’s License #_____________________ Social Security #___________________________

Occupation/Employer___________________________________________________________

Work Address_________________________________________________________________

May we contact you at work? Y N Best time to call?____________________________________

If you are a student…Which school do you attend?______________________________________

Parent’s Names___________________________ Parent’s Phone________________________

Permanent/Parent’s Address______________________________________________________

Fees are due at the time service is rendered unless prior arrangements have been made.

What is your preferred method of payment?

CASH CHECK DEBIT CARD CREDIT CARD

If you would like to pay by check or credit card we require your driver’s license #.

Balances outstanding over 30 days are subject to a 1.5% finance charge per month, as well as a late fee.

I hereby authorize the bank to release to Kutztown Animal Hospital information regardingthe status of my

accounts. I understand, and agree that any returned check is subject to a service charge.

(both parties must sign if a joint account)

Signature_______________________________________ Date____________________

Client will assume all collection and finance charges. We reserve the right to check your personal credit.

How did you become aware of our hospital?___________________________________________

If a personal referral, whom may we thank?_____________________________________________

PET INFO Name DOB/Age Breed Sex(spayed/ neutered) Color Tattoo or Chip #

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Pet #1

______________________________________________________________________________

Pet #2

______________________________________________________________________________

Pet #3

______________________________________________________________________________

Pet #4

______________________________________________________________________________

Please list any allergies, chronic illnesses, or major problems that any of your pets may have. ____________________________________________________________________________________

____________________________________________________________________________________