Client Information Sheet in Freeland, PA | Northeast Animal Hospital, Inc.

Client (owner) name
Client address
Street Address City State / Province / Region ZIP / Postal Code
Phone Number
Cell
Driver's license number
Email Address
Emergency Contact Number:
Emergency Contact Name
Pet's name
Species
- Dog
- Cat
Breed
Pet's age:
Color
Sex
- Male
- Female
Spayed or neutered (yes or no)
Purpose for today's visit
Were you referred? lf yes please include the name of who told you about us.
How will you be paying for today's visit?
Please initial next to each statement to indicate that you have read & understand them.
- A 24 hour notice will be required to cancel appointments. If we are not notified, a $50 fee will be added to your account.
- Any unpaid bill will be assessed a finance fee of 19% yearly after 30 days. After 60 days, we can refer this matter to the local magistrate.
Your signature*
Your Name
Date*

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