Client Information Update Form

To help keep our files up to date with your current information we would appreciate you taking the time to fill out this form. By doing so it will insure that we have your current information. Please print clearly.

Client*
First Last
Pet*
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
Driver's License (required if paying by check)
Email
Optional Information:
Spouse's Place of Employment
Spouse's Email Address
Spouse's Work Phone
Spouse's Cell Phone
We will be using email to send reminder information ( as a supplement to our usual reminder cards), as well as sending you our hospital newsletters. Your email address will be strictly used as a means to provide hospital newsletters. And communications with you. We will not be provided your e-mail to any outside sources.
Please indicate your choice as to email communication
- Yes, provide information through email
- No, do not send information through email
We appreciate your business and look forward to serving you and all of your pets needs.
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 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.

Monday: 8:00am-12:00pm & 2:00pm-6:00pm Tuesday: 8:00am-12:00pm & 2:00pm-6:00pm Wednesday: 8:00am-12:00pm & 2:00pm-4:00pm Thursday: 8:00am-12:00pm & 2:00pm-6:00pm Friday: 8:00am-12:00pm & 2:00pm-6:00pm Saturday: 8:00am-4:00pm Sunday: Closed

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Client Information Update Form

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Call/Text: 847-647-9325

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