Client Registration
Thank you for choosing LaCroix Pet Hospital. Our primary mission is to deliver the best and most comprehensive veterinary care available for your pet. An important part of the mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options. LaCroix Pet Hospital requires payment in full at the time services are rendered and/or products are purchased.
Payment Options:
Cash, Check, Care Credit®, Visa®, MasterCard®or Discover Card® ***LaCroix Pet Hospital charges $25 for returned checks.
For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier.
Name______
LastFirstMiddle
Address ______
Street
City______State______Zip Code______Cape Girardeau City Limits ______
*Requires special license yes no
Home Phone ______Cell Phone ______Work Phone______
Email Address ______*for Pet Portal
Soc.Sec.# ______Dr .Lic.# ______
Employer ______How Long ______
Employer’s Address ______Occupation ______
Please circle one - for secondary / emergency contact and enter their information below
SPOUSE SIGNIFICANT OTHER RELATIVE FRIEND OTHER______
Name______
LastFirstMiddle
Address ______
Street
City______State______Zip Code______Cape Girardeau City Limits ______
*Requires special license yes no
Home Phone ______Cell Phone ______Work Phone______
Employer ______How Long ______
Employer’s Address ______Occupation ______
Pet Information:
Pet’s Name______Dog / Cat
Breed______Purebred / Mix
Color______
Age______Birthday______
Sex - Male or FemaleSpayed/Neutered – Yes or No
Micro-chipped - Yes or NoMicrochip No.______
Prior Veterinary Information:
Name:______Phone #:______
Additional information______
______
______
Referred by ______
In case of default of payment, I promise to pay all collection costs and reasonable attorney fees incurred to effect collection on this account.
Signature of Client/Responsible Person______Date______
Client Communication Consent Form
Text Message Alerts
I authorize LaCroix Pet Hospital to send text messages to the provided cell phone number(s). Content of messages may include but not limited to, appointment reminders, non-emergency patient status updates and pictures. By accepting these terms I agree that all individuals associated with my account may receive text messages. Text message charges from my cell phone provider may apply.
Client’s Name: ______
For Text Messaging Please Circle: YES / NO
If yes please fill in info below:
Client’s Cell Phone Number: ______-______-______Iphone: yes / no
Client’s Additional Cell Phone Number: ______-______-______Iphone: yes / no
Please circle: YES / NO
I authorize LaCroix Pet Hospital to post photos of my pet on their Facebook page
Signature: ______Date: ______
LaCroix Employee Witness Signature: ______