E-Mail Address : Pet's Name (required) Age: Years, Months Type of Pet : (required) Canine Feline Avian Exotic Other Breed: Sex: (required) Male Female Neutered/Spayed Neutered Spayed Are your pet's vaccines current? Yes No Do you have pet's medical records? Yes No Medical records at another veterinary Practice? Yes No Name of Former Veterinary Practice May we request a transfer of records? Yes No Would you like us to call you for your appointment Reasons or conditions that prompted your visit? Special requests or conditions? Please list any additional pets here How did you hear about our hospital? Pet Store Yellow Pages Drive-by Live close Walk-in Previous client If referred by a client, who may we thank? Please Read I understand, by indicating I agree and submitting this registration, that I assume responsibility for all charges incurred in the care of my pet by the doctors at Sahara Pines Animal Hospital and that charges are due and payable at the time of service. Sahara Pines Animal Hospital does not provide any billing options (please ask about Care Credit payment plans). Payment may be accepted in the form of cash, personal local check (with a valid Nevada driver license), Visa, Mastercard, Discover, American Express and Care Credit. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Sahara Pines Animal Hospital's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.
I also certify that I am the owner or duly authorized agent for the owner of the above described pet(s) and authorize Sahara Pines Animal Hospital to examine, prescribe for or treat said pet(s). I have read this statement and - (required) I Agree I Disagree