Arkansas Veterinary Emergency Specialists - PDF document

1 Page 1 Arkansas Veterinary Emergency
Page 1 Arkansas Veterinary Emergency & Specialists – NEW CLIENT FORM Client In f o r m ation O w ner N a m e :_ C o - O w n e r /Sp o u s e N a m e: _ _ H o m e A dd res s :_ C i t y :_ State:_ Z ip:_ Pri m a r y Phone # :_ Sec o n d a ry Phone # :_ C o - O w n er P h o n e # :_ E m a il A d dre s s :_ E m p l o y e r :_ Dri v e r ’s Lic # DO B : Wo rk P h o n e: _ ** We m u st coll ec t Dri v e r’s L ic e n se a n d e m p l o y me n t i n f o r m a ti o n f o r c o ll ec t i o n pu r po s e s. W e a lso r e qu ire a p h o t o c o p y o f y ou r li ce n s e* * Patient In f o r m ation P a tient N a m e :_ D o g C at _ B r ee d :_ C ircle O n e: Male/I n tact Male/Ne u tered F e m ale/ I n tact F e m ale / Sp a y ed B irth Date / A g e :_ C o lor:_ A re Vacci n atio n s C u rre n t ? Y / N R ea s o n f o r R e f erral ( p ri m a r y c o m p la i n t):_ P lease li s t a n y o f y o u r p et ’ s d r u g alle r g ies or s p ecial p r ob le m s t h at w e s h ou ld kn o w a bo u t : What veterinarian referred you to Arkansas Veterinary Emergency & Specialist s ? Had you heard about our hospital prior to this referral? Yes No If yes, how: Did you bring (or mail in) X - rays and/or medical records from you

2 r veterinarian? Yes No OFF
r veterinarian? Yes No OFFI C E U S E O N LY RDVM N a m e :_ Clin i c N a m e : _ Clin i c Phon e : _ Clin i c F a x : Page 2 Arkansas Veterinary Emergency & Specialists – NEW CLIENT FORM Payment Information I understand that I am financially responsible to Arkansas Veterinary Emergency & Specialists for charges. I understand that payment is due in full at the time services are rendered. I agree to pay all interest, collection, legal, attorney or court fees in the event it becomes necessary to pursue the account for collection. We accept cash, checks, major credit cards and Care Credit. TeleCheck authorizes all checks. When you provide a check as payment, you a uth o r i z e u s t o u se i n f or m a t ion f r o m yo u r c h eck t o p ro c ess a o n e - t i m e p ay m e n t E l ec t r o n i c Fu n d s T r a n s f e r ( EFT ) , a d ra f t d ra w n f r om yo u r ac co un t or t o p ro c ess t h e p a y m e n t as a c h eck t ra n sac t i o n . Un less s p e ci f i c a l l y re qu es t e d , a l l p e t s n ee d i n g e m erge n c y c a re w h ile s t a yi n g in o u r h os p i t al w i ll b e t r e a t ed un t il th e o w n e r /a ge n t c an b e c o nt a c t e d . O w ner/A g ent Signature ( mu s t be ove r 18 y e a r s o f a ge ) D a t