Client Information Form - Knox Pet Clinic

Client Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Home Phone

Work Phone

Cell Phone(Required)

Employer Name

Employer Phone

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Pet Information

Name(Required)

Species(Required)

Breed(Required)

Date

Color

Sex

Male

Female

Spayed/Neutered?

Yes

Microchip

Are there any conditions or health history we should know about?

We want to make your pet famous! Do we have permission to take photographs of your pet to share on social media, our website, and printed materials?

Yes

Authorization

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet

Signature(Required)

Date(Required)

Financial Policy

Thank you for choosing Knox Pet Clinic. Our primary mission is to deliver the best and most comprehensive veterinary care available for your pet. An important part of the mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options. Knox Pet Clinic requires payment in full at the end of your pet's examination and/or at the time of discharge.

Payment Options: Cash, Debit or Credit Cards, Check, Scratchpay, and CareCredit® Healthcare CreditCard¹

Deposit & Billing: For some treatments or hospitalized care, a deposit may be required. Healthcare plans requiring comprehensive care or surgeries, will require a $100.00 deposit to begin your pet's treatment. We may offer in-house payment options on a case-by-case basis. We charge 1.5% interest on all outstanding account balances older than 30 days. If you have an account 90 days past due, Knox Pet Clinic may relinquish your balance owed to a collection agency. In the event it becomes necessary for Knox Pet Clinic to incur collection cost or institute suit to collect any amount due under this agreement, the undersigned also agrees to pay collection fees and expenses, including reasonable attorneys’ fees and court cost, plus all legal fees if incurred for collection and submits to jurisdiction and venue in Knox County, IL.

Additional Policy Information: Knox Pet Clinic charges $35 for returned checks. For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier. If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your pet.

By signing below, you agree to the foregoing terms of payment:

Client/Owner Name(Required)

First Last

Client/Owner Birthday

Client/Owner Social Security Number

Signature(Required)

Date(Required)