PATIENT REGISTRATION FORM

Welcome to the Lake Side Animal Hospital of Tilton. Please take a few minutes to fill out this form completely. We will be glad to answer any questions you may have.

Client Information

Last Name ____________________________________ First Name __________________________
 

Address ______________________________ City ____________________ State____ Zip________
 

Home Phone _________________           Work Phone ________________________

Spouse or Co-Owner __________________________ Cell Phone ____________________________

Referral ____________________________________ Email ________________________________
 

Employer _________________________________________________________________________

Patient Information

Pets Name _________________________    Sex:     M or F          Altered:   Y or N
 

Age or Birthdate ________________   Breed _______________________________

Microchip # ________________________    Color ________________________
 

Species (canine, feline, other) ________________________________________
 

Reason for Visit _________________________________________________________________

Payment is due at the time of service. We accept all major credit cards, Care Credit, and cash. Unfortunately we no longer accept personal checks and apologize for any inconvenience.

The client agrees that any amount unpaid after thirty days will be subject to interest at the rate of 2.5% per month (or 30% per year) until such unpaid amount is paid in full as well as monthly statement and handling fees. Additionally, the client will be responsible for the reasonable costs of collection of any such unpaid amounts, including collection and attorney fees.

Print Name ____________________________________________

Signature _____________________________________________    Date ___________________