Client Information Form

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone (Home)*
Phone (Work)
Phone (Cell)
Employer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Work Phone
Drivers License (if paying by check)

How did you learn about Niles Animal Hospital?
- Personal Recommendation
- Other Veterinarian
- Yellow pages
- Internet
- Other source
Please supply name of personal recommendation, veterinarian or other source:

All fees are due and payable on the day of treatment. A deposit for the first day of treatment is required on all hospitalized pets. Any outstanding bill will receive a monthly 1.5 % finance charge and a $3.65 billing charge at time of billing. I understand I am fully responsible for all charges involved with my pet and in case of nonpayment I will be legally responsible to pay Niles Animal Hospital the total medical bill, all finance and billing charges, a $ 25.00 collection fee, and all attorney’s fees and court costs involved with the case.
As the owner of this pet, I authorize treatment and payment in full including, if necessary, the above charges associated with the collection of the bill. I understand I may pay with Cash, Check, Visa, Mastercard or Discover.
Thank you for choosing our hospital, we do appreciate your business.
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Pet Information