Thank you for visiting our hospital. We look forward to getting to know you and your pet. Please help us to provide the best care possible for your pet by taking a moment to fill out this form. Client / Owner Information Name Occupation Address Address Cont'd City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Home Phone Cell Phone S. S # (Optional, but required if you do not have a Florida DL) Work Phone Email * Do we have your consent to place your pet(s) picture on our website or Facebook page? Yes No Any pictures taken will not be used for advertising purposes, will only be used for fun pictures on our website. Spouse / Co-Owner Information Name Occupation Cell Phone Work Phone Email How did you hear about us? How did you hear about us? - None -FriendInternetTelephone BookDrive By/Saw Our SignOther (Please fill in below) Other Doctor ReferralIf you have been referred to us by another veterinarian, please provide their information below. Doctor's Name Hospital Name State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Phone Please tell us about your pet(s) Name Type of Pet - None -DogCatOther (Please fill in below) Other Breed Color Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 Sex - None -MaleFemale Microchipped? Yes No Spayed / Neutered? - None -YesNo Please tell us about your pet(s) Name Type of Pet - None -DogCatOther (Please fill in below) Other Breed Color Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 Sex - None -MaleFemale Microchipped? Yes No Spayed / Neutered? - None -YesNo Please tell us about your pet(s) Name Type of Pet - None -DogCatOther (Please fill in below) Other Breed Color Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 Sex - None -MaleFemale Microchipped? Yes No Spayed / Neutered? - None -YesNo Agreement Professional fees are to be paid at the time services are rendered. Park Veterinary Hospital is not in the business of advancing credit to its customer. All accounts will be billed monthly and all outstanding balances are due and payable when rendered. Any account which is not paid in full will be assessed a service charge of $7.50 or 1.5% of the unpaid balance, whichever is greater. If payment cannot be made in full Park Veterinary Hospital reserves the right to withhold your pet until payment is met at an additional charge of the nightly boarding rate. THERE IS A $350.00 SERVICE FEE FOR ANY ACCOUNT THAT MUST BE TURNED OVER TO OUR COLLECTION DEPARTMENT. In the event that suit is filed, venue will be Broward County, Florida. Furthermore, I agree that I will be held personally responsible for all costs associated with the collection of this account, including but not limited to: a collection agency fee and court costs. I also understand that all returned checks will be assessed a $35.00 service charge. Please sign your name below using your mouse as a cursor: Signer Name *
