NSAC Client Registration Form

Client Information
Name

First NameTitle & Last Name
Title & Spouse Full Name
Mailing Address:
Street/Apt#
City, State/Zip Code
Home Phone:
Cell Phone #1
Cell Phone #2:
His Employer:
His Work#:
Her Employer:
Her Work#:
Email Address:
example@example.com
Previous Veterinarian:
May we call for records?
Alternate Contact (not living w/you):
Phone#:
How did you hear about us? (pick one)

Sign/LocationYellow PagesFacebookBillboard/Ad

PAYMENT IS DUE IN FULL AT TIME OF VISIT.

A deposit is required for extensive or emergency procedures, with balance due at time of release. There is a $35.00 service charge on all returned checks. To prevent the spread of parasites and infectious diseases, all hospitalized and boarding patients must be current on vaccinations and free of internal and external parasites. Your signature authorizes the doctor to provide these vaccinations and/or bathing/parasite control as needed. By signing below, you authorize your pet’s medical records to be released to city/state officials, requesting veterinarians/clinic/hospitals and your pet’s name and photo used on our Facebook page and/or hospital publications (your last name WILL NOT be used).
How will you be paying today? (We do impose a 3% surcharge on each credit card transaction.)

CashCheck (TX DL required)VisaMastercardDiscoverAmerican ExpressCare Credit
I am the owner (representative) of the animal(s) listed above and will be responsible for payment of services rendered. In the event that collection efforts become necessary, I agree to pay for the costs of interest, collections, attorney’s fees, and court costs.
Signature

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Date

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