CLIENT INFORMATION SHEET
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Due to an increase in outstanding and uncollectible accounts, we are now required to have all of the following information. .
NAME: HOME PHONE:
ADDRESS: TIME THERE:
CITY: STATE: ZIP CODE:
EMERGENCY CONTACT: PHONE:
'TN DRIVERS LICENSE #: SOCIAL SECURITY#:
BIRTHDATE YEAR: MONTH: DAY:
HOW DID YOU HERE ABOUT US?
REFERED BY: ADVERTISEMENT: OTHER:
FOR SICK, INJURED BOARDING ANIMALS YOUR VETRINARIANS NAME:
I understand that. to prevent the spread of infectious Disease and parasites, all boarded animals must be current all vaccines and free of fleas aric worms. I authorize the Animal Country Club to provide services services and also emergcncy care if needed at the discretion of our staff
I understand that by initiating this relationship with, Animal Country Club that I' am responsible for full payment of all fees incurred and that payment 'is due at the time services are rendered. I also understand that unpaid Fees are subject to interest and / or collection and attorney fees. I understand there will be a $20.00 returned check fee on any non‑sufficent funds Checks.
S I G NA TU R E D ATE