CLIENT INFORMATION

Client Information

Date:

Name: *

First

Middle

Last

Address: *

Address Line 1

City

State

Zip Code

Cell Phone: *

Home Phone:

Email Address: *

*Information will not be sold or shared for mass email purposes -for hospital use only

Employer:

Work Phone:

Secondary Owner:

Phone:

Emergency Contact

(not living with you):

Phone:

PATIENT INFORMATION

Patient’s Name: *

Species: Dog / Cat / Other: *

Date of Birth/Age:

Breed:

Color:

Sex:

Male Intact
Male Neutered
Female Intact
Female Spayed

Pet Insurance Carrier:

Policy Number:

Can Coral Springs Animal Hospital take photographs of this pet to use for social media, their website, and/or advertising?

Yes
No

Signature *

HOW DID YOU HEAR ABOUT OUR HOSPITAL?

How Did You Hear About Our Hospital?

Coral Springs Animal Hospital -Client / Employee: (Please give us their name so we may thank them)
Website
Social Media
AAHA Referral
Location proximity to home
Animal Control / Humane Society
Search Engine (Google, Duck Duck Go, Yahoo, Bing, etc.)
Heron Bay Living Magazine
Other

PAYMENT POLICY:

ALL FEES FOR PROFESSIONAL SERVICES ARE DUE AND PAYABLE AT THE TIME SERVICES ARE RENDERED. It is our policy to provide you with a written estimate of fees if you wish, especially for any case where in-hospital or emergency care is necessary. A deposit prior to treatment is required. The balance is due at discharge. I agree, in the event that any amount becomes past due more than 30 days, I will pay interest thereon at 18% per annum (1.5% per month), plus a monthly billing charge of $5.00 from the date the charges were incurred. In the event it becomes necessary to collect fees through the services of an attorney or other collection agency, either prior to or at trial, I agree to pay all reasonable attorney’s fees and/or collection agency fees, and reasonable attorney’s fees incurred. I am the legal owner or the representative of the legal owner of the animal being presented for treatment, and I am over 18 years of age. Notwithstanding anything to the contrary above, if this Agreement is being signed by an Agent of the Authorized Person (for example, a pet sitter or pet transporter), it is agreed and understood that such Agent is NOT responsible for any fees related to the care and treatment of the pet. Only the Authorized Person and/or Co-Owner is responsible for such fees.

I have read and understand the Payment Policy.

SIGNATURE: *

For Internal Use Only: Date:

CSR Initials:

Proof Of Ownership

COPY OF VALID DRIVER’S LICENSE OR OTHER PHOTO ID REQUIRED FOR PROOF OF OWNERSHIP.

Primary Care Registration Form
Coral Springs Animal Hospital