Client Form

REQUIRED FIELDS [*]

CLIENT INFORMATION
Responsible Party/Owner

Today's date:

Enter your full name: [*]

Spouse name:

Full Mailing Address (Address, city, state, zip): [*]

Previous Address (Address, city, state, zip): [*]

Email Address: [*]

Home Phone: [*]

Work Phone:

Cell Phone 1:

Cell Phone 2:

Place of Employment:

Drivers License Number and Issuing State: [*]

PET INFORMATION

Pet's Name: [*]

D.O.B: [*]

Dog or cat? Select one: [*]
SELECT ONE Dog Cat

Breed:

Color:

Sex? Select one: [*]
SELECT ONE Female Male

Spayed / Neutered? Select one: [*]
SELECT ONE Yes No

I, the undersigned, agree the fees charged are a legal and lawful debt and agree to pay said fees including the cost of collection (33 .33 %), attorney fees, and/or court costs if such be necessary. I waive now and forever my rights of exemption under the laws of the state of Alabama and any other state.

I, the undersigned, give explicit prior consent to the Ark Animal Hospital, its employer and agents to contact me at any/all phone numbers, including cell phone numbers, for the purpose of treatment and payment.

* All fees are due at the time sell'Vices are rendered.* We accept cash, check, Visa, Master Card, Discover, American Express and Care Credit.

Entering your name below will be your digital signature:

The following person(s) are authorized to bring this pet in for treatment or to pick up after treatment (List up to four people).