Owner Information

Primary Owner *

Phone *

Secondary Owner *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Emergency Contact

Patient Information

Name *

Species?

Cat
Dog

Breed

Birthday

Color/Markings

Sex of Patient

Male
Female

Is the Patient Spayed/Neutered?

Neutered (Male)
Spayed (Female)
No

Does Patient have a Microchip?

Yes
No

Microchip

Please list any current medications, allergies, and a brief medical history if any

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
No

I hereby authorize the veterinarian to examine, prescribe for, and treat the above-described pet.

Signature *

Clear Signature

Date *

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 this 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 or at the time of discharge.

Payment Options:

Cash, check, debit or credit cards, the AllPet Card*, Scratchpay payment plans*, and CareCredit Healthcare credit & card* *subject to credit approval

Deposits & Billing:

For all surgical procedures, healthcare plans requiring hospitalization, and some treatment plans, a deposit of $100 will be required before the start of your pet's treatment.
Konx Pet Clinic reserves the right to charge a late fee of $10 for any appointment that is more than 10 minutes late.
Knox Pet Clinic reserves the right to charge a cancellation fee equal to the exam fee for any appointment canceled with less than 24 hours notice.
Knox Pet Clinic reserves the right to charge a cancellation fee of $100 for any surgical procedure that is canceled with less than 48hours' notice.
If a client incurs two cancellation fees, they will be required to pay those fees and make a non-refundable deposit of $50 prior to booking another appointment.

Additional Policy Information:

Knox Pet Clinic charges a $35 fee for all returned checks.
Knox Pet Clinic charges a 1.5% finance charge for any account with an outstanding account balance that is older than 30 days.
Accounts more than 90 days past due will be relinquished to a collection agency.
- In the event it becomes necessary for Knox Pet Clinic to incur collection costs 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 costs, plus all legal fees if incurred for collection and submits to jurisdiction and venue in Knox County, IL.
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 help you and to provide the best veterinary care available for your pet.

Acknowledgement

By signing below, I am agreeing to Knox Pet Clinic's Financial Policy:

Client/Owner Name (Please Print) *

First

Last

Client/Owner Birthday

Signature

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Date

Client Information Form