Animal Medical Clinic of Goose Creek

ANIMAL MEDICAL CLINIC OF GOOSE CREEK

102 CENTRAL AVENUE

GOOSE CREEK, SC, 29445

(843) 569-3647

Date ______

Name ______

Spouse or Significant Other ______

Address ______

City ______State ______Zip Code ______

Primary Contact Phone #______Cell Phone ______

E-mail Address (for reminders)______

Does your pet currently have Pet Insurance?

Insurance Provider______

Previous Veterinarian ______

How many pets are in your family? Dogs____ Cats____

How did you find out about our veterinary services?______

Do you currently use the services at the Goose Creek Bed and Biscuit? Yes / No

May we use your pet’s photo on our website or social media pages? Yes/ No

Are you or your spouse active duty or retired military? Yes/ No

*If yes please provide a military ID

Authorized person(s) to make medical financial decisions for your pets:

Medical:

Financial:

PAYMENT POLICY

PLEASE READ AND SIGN

We will be glad to provide you with a written treatment plan. Please let our receptionists or nurses know if you would like to have one for your appointment. We require a deposit (half of the written treatment plan) for all hospitalized patients, surgeries and emergencies. For your convenience, as forms of payment, we accept Visa, MasterCard, Discover, American Express, Care Credit, Debit cards, personal checks, and cash. All payments are to be made as services are rendered. Accounts that are not paid in full, are subject to a monthly interest rate of 1.8 %. Interest per year is not to exceed 21.6 %. Clients are responsible for all charges incurred and any collection fee necessary to collect on overdue accounts. A returned check fee of $25.00 will be charged for any returned checks.

CLIENT SIGNATURE □ By checking the box, you are authorizing this as your electronic signature

REVISED AUG 2014