New Client Information Form

Note: The above information is only required for acceptance of personal checks.

Do you have pet insurance?

Information About Your Pet

PET NUMBER 1

PET NUMBER 2

PET NUMBER 3

PET NUMBER 4

Additional Information

Is your pet currently receiving any medications?

All Fees are Due and Payable Upon Completion of Services

Payment in full is expected when treatment is performed or animal is discharged. In case of emergency hospitalization, deposit arrangements must be made with the receptionist. On your request we will provide you with a written estimate of fees before care is provided.

I understand and agree that I am financially responsible for payment in full for all services and products received from and/or provided by Murphy Road Animal Hospital, P.C. I also agree by signing below to take financial responsibility in the event the Doctor or Murphy Road Animal Hospital, PC suffers damages due to treatment that was fraudulently or improperly authorized. I understand that should I fail to honor my financial obligations with this facility, the entire balance shall be considered in default and immediately become due and payable. In addition, I understand the costs of collection and reasonable attorney fees necessary to collect the full amount due will be added to the balance. All unpaid balances shall be assessed interest fees of 1.75 percent per month (21 percent per year) beginning on the date of the service.

Photos may be taken of your pet by Murphy Road Animal Hospital, P.C., tcards. Please check here if you wish or do not wish to have your pet's photo taken.

Enter the verification code in the box below.