Doskey Mobile Veterinary Care, L.L.C. New Client Information

Doskey Mobile Veterinary Care, L.L.C.
New Client Information Form
Phone: (504) 812-5986 Fax: (504)301-9380

Thank you for choosing Doskey Mobile Veterinary Care, L.L.C. for the care of your animals. Please fill out the information below so that we may keep a health record for reference.

Title Your Name

Title Spouse/Parter Name

Address

City, State, Zip

Home Phone

Cell/Mobile Phone

Work Phone

Owner Information
Place of Employment

Position

DL or State ID #

State Issued?

Your Email Address:

Spouse/Partner

Place of Employment

Position

DL or State ID#/State Issued

Work Phone

Cellular Phone

How did you first become aware of our Mobile Care Practice?

Previous Client
Another Hospital (if checked, name of hospital)
Yellow Pages
Personal Recommendation (if checked, whom may we thank?)
Other (if checked, specify)

*The following individuals are authorized to make health and financial decisions for all my current and future pets. I understand that I am responsible to keep this information current and that my outstanding charges on this account will be my responsibility:
Authorized Health and Financial Decisions

TO HELP PREVENT THE SPREAD OF INFECTIOUS DISEASES, ALL HOSPITALIZED AND BOARDED ANIMALS MUST BE CURRENT ON ALL VACCINATIONS REQUIRED BY THIS PRACTICE, AND BE FREE OF EXTERNAL PARASITE INFESTATION.

Name of past veterinarian? Phone

Today's payment will be: Cash Check Visa MasterCard Care Credit

***ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED*** When extensive care is indicated, a deposit may be required up front. A written estimate will be provided upon request. Should I (the customer) fail to pay for any services rendered by Doskey Mobile Veterinary Care, L.L.C., I will be responsible for all service charges (18%) and collection charges (33%) incurred by the Practice. There is a $35.00 NSF fee on checks returned for non-payment.

Date

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