Henrietta Animal Hospital, PLLC
First Time Client Credit Form  

Thank you for giving us the opportunity to care for your pet.  So that we may be better able to meet your needs, please complete the following
q   Dr.         Owner: _____________________________ Telephone: Home:________Work:______
q   Mr.        Address: ____________________________ [] Own  []Rent Employment____________
q   Mrs.      City/State:___________________________________________ Zip Code:__________

CREDIT INFORMATION
Driver’s License ID Number _______________________ Expiration Date___________ State_______
Social Security Number ___________________________ Date of Birth ________________________
The undersigned acknowledges receiving services and certifies that I will take financial responsibility.  In the even that payment is not received and my account is placed for collection, the undersigned agrees to pay in addition to the amount due, service charges, in the amount of 1.5% per month (18% per annum) an amount equal to all collection expenses, including reasonable attorney’s fees in the amount of 33 1/3 % of the amount placed for collection.  I authorize the Animal Hospital to check my credit record and to verify my credit, employment and income references.
Dated ______________________________________

Witness ____________________________________            Signature _________________________
All fees are due upon rendering of services.

Patient Name ___________________________ [ ] Dog  [ ] Cat  [ ] Other _______ Breed___________
Color ____________ Sex [ ] M [ ] F  Spayed or Neutered? [ ] Yes  [ ] No  Birth Date ______________
Vaccinations Date:
Dog                  Rabies ___________ Distempter/Parvo _______________
Cat                   Rabies ___________ Distempter______________ Feline Leukemia_______________
Other _______________________________________________ Where Given __________________
Diet _________________________ Reason for Visit _______________________________________

How did you become aware of our hospital?  [ ] Yellow Pages [ ] Clinic Sign [ ] Referring Veterinarian
[ ] Personal Recommendation _______________________________________________________
                                              (Name)                                    (Address)
Have you ever been to a Veterinarian before?    [ ] Yes   [ ] No  If so, where? ____________________
If so, is there a reason for changing? ___________________________________________________

Is there a particular area of interest that we could possibly provide with more information?
__________________________________________________________________________________
Do you own other pets? _______________________________________________________________