New Client RegistrationNEW CLIENT REGISTRATION FORM Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneWork PhoneSpouse Name Name Spouse's PhoneAlternative Contact Name Alternative Contact 's PhoneEmail Drivers License No.*Driver's License State*How did you hear about us?Patient Name* Name SpeciesBreedColorSex Male Female Spay/Neuter Yes No Patient Name (2) Name Species (2)Breed (2)Color (2)Age (2)Sex (2) Male Female Spay/Neuter (2) Yes No Patient Name (3) Name Species (3)Breed (3)Color (3)Age (3)Sex (3) Male Female Spay/Neuter (3) Yes No Patient Name (4) Name Species (4)Breed (4)Color (4)Age (4)Sex (4) Male Female Spay/Neuter (4) Yes No Previous Medical Concerns: I hereby authorize Seven Hills Veterinary Clinic to examine, treat and prescribe for the above described pets. I assume responsibility for all charges incurred in the care of the(se) animal(s) and understand that all fees are due on the day of service. For your convenience we accept cash, personal checks, VISA, Master card, Discover and American Express. There will be a minimum returned check fee of $25.00. Should any default occur, all outstanding balances will incur a service fee of 1.5%. Service fees are applied monthly and will be added to your balance until paid in full. The client shall remain liable for any deficiency resulting from any amount remaining unpaid and shall pay same to Seven Hills Veterinary Clinic.Signature* Print Name as Signature Date* MM slash DD slash YYYY CAPTCHA
