Last narne (Apellido): First name (Nombre)

Last narne (Apellido): First name (Nombre)

cLrEI.{T TNFORMATION (INFORMACION DE CLIENTE)
Last narne (Apellido):
First name (Nombre):
Address (Direcci6n):
apt#
Zip code (C6digo postal):
State (Estado):
City (Ciudad):
Cell phone:
Home phone:
Horv did you hear about us?
Ernail:
pET TNFORMATION (TNFORMACION Dtr MASCOTA)
Pet (Mascota) #2
Ppt (Mascota) #1
Pet {Mascota}
Lta
+i1
Name of pet {Nombre de
mascota)
Breed (Raza de mascota)
Color
Approxirnate age (Edad
aproximada)
Gender, spayed/neutered
Genero, castrado o
esterili zada
Cautions (Precauciones)
Special Instructions
(Instrucc iones e spec iales)
Reason for appointment:
Method
of
Payrnent (Forma de pago):
i_J
Debit/Credit Card (de ddbito o de crddito tarjeta)
*
Cash (Efectivo)
f"-
i-l
I understand that
the exam is $65, everythirg etse costs extra. For surgeries, there
will
be a down payment.
I understand thet
ifl do not
pay, my tccount will be subject to eost ofcollection, attorney fees, including intercst (eny balance that is carried over a period of30 days
will accrue a monthly linance chrrge of 1,5-l8Yo per annum).the hospital staffwill provide an estimate ofcurrent and anticipated
charges any time I rcquest one. I am reqursting thet veterinary care be provided for pets Bresented by me or ruy rgents. I understand
that t am financially responsible for all serrlccs provided.
I agree not to disparnge or defrme {any negative statements, reviewg or comments, writtcn, oral, or via electronic communication) the
Rego Park/Forest Hills Yeterinary Clinic
Signature(Firma)
Date(Feche)