Welcome To Whitney Veterinary Hospital and Cat Care Clinic!
Patient/Client Information
Thank you for giving us the opportunity to care for your pet. Please help us meet your needs better by taking a moment to complete both pages of this information sheet.
Owner's Name__________________________Spouse/Other________________________________

Children(first name & ages)_______________________________________________________

Address____________________________________City________________State_____Zip______

Home Phone______________Work Phone______________Cell Phone_________________

E-Mail Address_____________________________________

Employer's Name & Address_________________________________________________________

Spouse's/Other's Employer & Address_______________________________________________

At what time_____and at what phone number____________is it best to call about your pet?

In case of Emergency, please call_______________at telephone number____________
How did you first hear of our hospital?
Yellow Pages
AAHA referral 		Hospital Sign
Other_________________________
Individual; Is this someone we may thank?___________________________
Who is Responsible for this Account?___________________________________
Indicate the Payment Methods You Will Be Using:
Cash____Check____Discover______Mastercard____Visa______

Professional Fees Are Due At The Time Services Are Rendered.

On your request, we will provide you with a written estimate of fees for any hospital treatment, emergency care, surgery or hospitalization. A deposit prior to treatment may be required depending on the amount of the estimate. Accounts not paid within 30 days are subject to an interest finance charge computed at a "periodic rate" of 1 1/2% per month on the unpaid balance (18% annually). The minimum monthly finance charge is $5.00. I agree that if I fail to make payment in full (in a timely manner) and my account becomes past due, I shall be liable for and agree to pay, all collection agency fees (not to exceed 33.3%), reasonable attorney's fees and court costs.

Owner's/Spouse's/Co-Owner's/Agent's Signature:

X_________________________________________Date_____________________
Please complete the patient information on page 2