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Our New Client Form

ANIMAL HOSPITAL OF MACOMB & PET AUTHORITY ANIMAL HOSPITAL

WELCOME! Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following, to the hospital where you scheduled your pet’s appointment.

E-mail Address: *
Select which location *
Your Name *
Your Date of Birth (m/d/y) *
Address *
City *
State *
Zip Code *
Place of Employment *
Business Phone *
Business e-mail address
Drivers License *
Full Payment is Due at the time services are rendered, we are not able to do any billing. We do accept credit cards & Care Credit. Please indicate choice of payment *	Cash Visa MasterCard Discover Care Credit
How did you become aware of our Clinic?	Sign Yellow Pages Internet Other
Personal Recommendation (whom may we thank?)
IN CASE OF AN EMERGENCY AND WE ARE UNABLE TO REACH YOU, WHO SHOULD WE CONTACT? *
Phone *
Do you give this person the authority to make medical decisions for your pet? *	Yes No
Pet Name *
Breed
Date of Birth
Color
Sex *	Spayed Neutered
Pet Name #2
Breed #2
Date of Birth #2
Color #2
Sex #2	Spayed Neutered
Pet Name #3
Breed #3
Date of Birth #3
Color #3
Sex #3	Spayed Neutered
Signature of Person Responsible for Pet *
Date *


* Required	Create Email Forms

We will gladly prepare a written estimate if you desire (please ask doctor, technician, or receptionist) ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICED ARE RENDERED. We accept most major credit cards. Personal checks will be accepted on future visits only for new clients (with proper identification) There will be a $25.00 service charge for any check returned unpaid. The signature above authorizes this level of preventive care and that the above information is accurate.

I understand the above terms and contract and agree to pay in full. I, the undersigned, understand that if this account is not paid in full, it will be turned over to a collection agency, or legal system. All fees including court, attorney and collection fees, will be applied to the collection of the above.