White Oak Animal Hospital
New Client Registration
Children (name & age):
Spouse's Employer Name:
In case of
at telephone number:
Approx. Date of Birth:
List the names and types of any other animals that you own:
How did you first hear of us?
If other, please specify:
Were you refferred by another client?
Individual we may thank?
Are there any personal issues you would like us to be aware of? (i.e. allergies, claustrophobia, fear of animals) :
I assume responsiblity for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment.
If this account becomes delinquent, I hereby agree to pay 33 1/3% attorney fees and all other costs to collect this debt.