Action Care Mobile Veterinary Clinic, LLC
Mechanicsville, Maryland
301-884-PETS (7387)
Client Registration
Name:
Mr.,Mrs.,Miss, Dr. ________________________________________________ Date:___________________
Driver’s License or
I. D. Card Number: _______________________ Expiration date:______________________
Social security
#______________________________________
Address:
______________________________________________________________________________________
Street
number and name
City
State
Zip Code
Occupation: _______________________
Employer:
_________________________________________________
Spouse [
] Partner [ ] Co-owner [ ] Name:
______________________________________________________
Telephone:
Home:
____________________________Work:________________________
Cell:__________________________
How
did you hear about us?
____________________________________________________________________
If
referral, whom may we thank?
________________________________________________________________
Reason
for leaving previous veterinarian:
________________________________________________________
Email Address: ________________________________________________________________________________
PROFESSIONAL
FEES ARE TO BE PAID AT THE TIME SERVICES ARE PERFORMED
In
admitting my pet(s) for diagnostics, treatment, or surgery, I authorize the
veterinarians of Action
Care Mobile Veterinary Clinic, LLC,
and their support staff, to administer such treatment and/or perform such
diagnostic or surgical procedures as deemed necessary.
It
is understood that an estimate of charges will be given for services. No
guarantee or assurance can be made as to the results that may be obtained.
Further,
I understand that a deposit of at least 50% is required before services are
performed and all final charges must be paid at time of discharge. I assume full financial responsibility for
all charges incurred by my pet. I realize that these charges may exceed a given
estimate if complications arise. I understand that I will be contacted prior to
treatment, if possible, should complications occur.
No
billing or credit is available through our service. Please indicate your choice of payment:
Check
[ ] Cash [ ] MC/Visa [
] Other: ________________
Signature:
______________________________________________________
Date:_______________________
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