New Client Form - Hillsboro Vet

New Client Form
Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following:

Date*
Name
Spouse's Name

Address
City
State
Zip
County

Email:
Cell Phone:
Home Phone:
Work Phone:
Spouse's Cell:

Driver's License
Social Security

How did you become aware of our clinic?
Please check ALL that applyDrove ByWebsiteGoogle SearchCommunity EventOther
OR Personal Recommendation
Pet #1
Species
Breed
Date of Birth
Color
Sex (spay or neutered)
Pet #2
Species
Breed
Date of Birth
Color
Sex (spay or neutered)
Pet #3
Species
Breed
Date of Birth
Color
Sex (spay or neutered)
Pet #4
Species
Breed
Date of Birth
Color
Sex (spay or neutered)
Pet #5
Species
Breed
Date of Birth
Color
Sex (spay or neutered)

Patient Policies
Payment Policy: Please read the following carefully
I have provided information that is true and correct to the best of my knowledge. I hereby give Countryside Veterinary Service, LLC permission to examine and treat my animal. Payment is due upon completion of the visit. Countryside Veterinary Service accepts cash, checks, and Visa, Mastercard, Discover & debit cards. If legal action is necessary to collect outstanding fees incurred, including but not limited to filing fees, court cost, & attorney or agent fees. We reserve the right to charge a service fee of 18% each month on any unpaid balances. Any animal left more than 10 days after the Completion of services will be considered abandoned and will become the property of Countryside Veterinary Service. Dr. Stacey Funderburk will have the sole discretion over what to do with the animal.
By checking this box, I represent that I am electronically signing these documents which will have the same effect as the execution of these documents by a written signature.I Accept

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