Client Information Form

Client Information

Client Name(Required)

First Last

Phone

Cell

Date of Birth

Employer

Address

Street Address Address Line 2 City State ZIP Code

Spouse / Significant Owner Information

Spouse / Significant Other Name

First Last

Phone

Date of Birth

Other Contacts

Others allowed to request services/medications and/or bill to my account(if applicable) Must be at least 18 years old.

How will you be paying for each visit?

If paying by check we have a $30.00 return check fee for any check that is returned unpaid.

If prior arrangements have been made for payment the following will apply: Any unpaid balances will be billed on a monthly basis. Any balances unpaid for more than 30 days are subject to an 18% interest charge. A payment on account is due a minimum of every 30 days. If no payment is received within 60 days this account will be turned over to small claims court or our collection agency.

You agree to reimburse us the fees of any collection agency, which may be based on a percentage at a maximum of 33% of the debt, and all cost and expenses, including reasonable attorneys’ fees, we incur in such collection efforts.

I also understand that by signing below this contract will remain in affect until further notice. This contract will cover any and all services rendered by Lahontan Valley Veterinary Clinic for any animal on file with you.

Client Information Form