New Client Form Date Person Responsible For Account*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell PhoneText MessagesYesNoEmail Driver's License #Employer NameEmployer PhoneEmergency ContactEmergency Contact PhoneUntitledReferred ByWebsiteSocial MediaEstablished ClientOtherRESPONSIBILITY AND FEE AGREEMENTProfessional services are rendered to the client's animal. Fees are due at the time of service. Balances outstanding 30 days after services are rendered are considered delinquent. I AM RESPONSIBLE FOR PROMPT PAYMENT OF THE ACCOUNT. I agree to pay amounts and charges incurred by myself and members of my family for services rendered. Failure to make payments when requested or agreed is basis for legal action and I AGREE TO PAY ALL COSTS OF COLLECTION, INCLUDING AN ATTORNEY'S FEE. I hereby waive my rights of exemption under the laws of the state of Alabama and any other state. I AGREE TO PAY 1.5% PER MONTH (18% ANNUM) FINANCE CHARGE ON ANY BALANCE UNPAID AFTER 30 DAYS AND A $29.00 PER MONTH LATE FEE.Confirmation* I Agree CAPTCHA
