Client

First Name
Last Name
Significant Other
Address
City
State
Zip
Primary Phone
Cell Phone
Cell Carrier (for texts)
Work Phone
Other Phone
Who's?
Emergency Contact Name
Emergency Contact Phone
Email Address
How Did You Find Us?
Method Of Payment
- Cash
- Credit Card
- Care Credit
Please Note Our Hospital's Financial Policies:
1. Payment is due, in full, at the conclusion of the visit or service. WE DO NOT BILL. We do accept Care Credit. Whole Pet Wellness Center DOES NOT Extend Credit or Arrange Payment Terms. All hospital or surgical estimates are to be paid half down in advance of service and balance paid in full at end of service. (Initial)
2. I understand that failure to pay will result in full collection effort being taken and I will be responsible for all collection costs including but not limited to, Court costs, serving by private processor or sheriff, and any other fees incurred. (Initial)
Whole Pet Wellness Center offers excellent Veterinary Care at value driven prices. We sincerely hope you understand our policies and they are in place to keep your Veterinary Medical expenses within at a reasonable cost. I have read the above reference policies. I understand them completely and give notice of my intention to fully adhere to their provisions. Owner/Agent Signature:
Date

Please Note Our Hospital's Financial Policies: