New Client Form - Healthy Pets of Lewis Center

    This person is authorized to make medical decisions and will be responsible for payment. You as the owner are responsible for removing this person if you wish not to have them listed on this account.

    (The purpose of email is so that you will have availability to your pets shot records and will receive reminders from our clinic for annual vaccines)

    Pet No. 1.

    Pet No. 2.

    I/we understand the amount is due and payable at the time that services are rendered. Due to the increased number of fraudulent checks, there will be NO checks accepted on ANY New Client until that client has become established with our office. All account balances are due upon release of your pet. Feel free to discuss your pet’s treatment program and its cost with the doctor at any time. If Healthy Pets of Lewis Center, Inc. should require outside agents to collect any default amounts, all reasonable collections, finance charges, attorney fees and court costs will be my/our responsibilities as well as all principle costs due.

    Signature of owner or authorized agent for owner