Summer Street Animal Clinic

Client Information

First Name*:	Middle Initial:	Last Name*:

Address*:

City*:	State*:	Zip*:

Email:

Home Phone*:	Cell Phone:	Work Phone:

Birthdate:	Bank:	Employer:

How did you learn about our practice?

Des Moines County Greeter	Doctor
Related to Employee	Previous Client
Website/Internet	Yellow Pages/Phone Book
Word of Mouth - If so, who can we thank?
Other - If so, please explain:

Spouse/Co-Owner Information

First Name:	Middle Initial:	Last Name:

Home Phone:	Cell Phone:	Work Phone:

Birthdate:	Bank:	Employer:

Emergency Information

Nearest Relative Contact Name*:
Nearest Relative Contact Phone*:
Other Phone Numbers:

Payment

I hereby authorize the veterinarians at Summer Street Animal Clinic to examine, prescribe for, or treat any animals brought in under my care. I assume responsibility for all charges incurred with animals under my care. I also understand that payment is expected at time of release and that a deposit may be required for surgical procedures and/or hospitalization. I am aware that written estimates can be prepared upon request.

Summer Street Animal Clinic accepts cash, check (with proper i.d.), Visa, MasterCard, Discover and CareCredit.

I agree to the above payment terms*:
Date: