New Client Form | West Lauderdale Veterinary Hospital

Date

MM slash DD slash YYYY

Person Responsible For Account*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Cell Phone

Text Messages

Yes
No

Email

Driver's License #

Employer Name

Employer Phone

Emergency Contact

Emergency Contact Phone

UntitledReferred By

Website
Social Media
Established Client
Other

RESPONSIBILITY AND FEE AGREEMENT

Professional 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

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