Day Hollow Animal Hospital PC

Welcome to

Day Hollow Animal Hospital PC

Thank you for selecting us to care for your pet.

Please provide us with your personal information by completing this form. Thank you!

What led you to choose Day Hollow Animal Hospital?

Name /

Home Phone #

/
Address / Cell Phone # /
City / State / Zip Code /

E-Mail Address

/
Employer /

Work Phone #

/
Spouse or
Co-Owner / Co-Owner
Cell Phone#
Co-Owner Employer /

Co-Owner

Work Phone #

/
Primary financially responsible contact or person making decisions about your pet’s care:
Emergency Contact: /

Phone #

Phone #

Pet Information

Name Breed Gender: Male/Female

Date of Birth/Age Color Neutered? Yes/No

(PLEASE LIST ADDITIONAL PETS ON BACK OF THIS FORM)

Payment Information

Payment is required at the time services are rendered

Please check preferred method of payment:

q Cash

q Credit Card (MasterCard, Visa, American Express, Discover)

q Check – REQUIRES DRIVERS LICENSE

I agree to pay a $25.00 service charge each time a check tendered as payment on my account is returned for any reason.

If for any reason I have an outstanding balance: I agree that a SERVICE FEE equal to 1.5% / Month (18% annual percentage rate) or a minimum charge of $1.00 per statement which ever is greater, will be applied to any balance outstanding 30 days or more. Statements are issued the last day of each month. Balances outstanding for more than 60 days with out payment will be submitted to a collection service. Collection Service fees (up to 35% of the amount owed) and any legal fees will be added to your balance due. The Day Hollow Animal Hospital may decline additional treatment until the outstanding balance is paid in full.

I understand and agree to these terms.

Signature Date .

Additional Pet Information

Pet Information

Name Breed Gender: Male/Female

Date of Birth Color Neutered? Yes/No

Pet Information

Name Breed Gender: Male/Female

Date of Birth Color Neutered? Yes/No

Pet Information

Name Breed Gender: Male/Female

Date of Birth Color Neutered? Yes/No

Pet Information

Name Breed Gender: Male/Female

Date of Birth Color Neutered? Yes/No

Pet Information

Name Breed Gender: Male/Female

Date of Birth Color Neutered? Yes/No