Client Registration Form

Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Main Phone
Cell / Alternative Phone
Email
How did you become aware of our hospital?
Payment Policy:
Full payment is required upon rendering services. Deposits are required on major medical/surgical cases/trauma cases and emergency work where hospitalization is required.

Methods of Payment Accepted: E-Transfer/Cash/Debit Card/ MC/ Visa/ Medicard

Note: We DO NOT accept cheques or carry open accounts and hope the above alternatives are convenient for you.

By signing below, I agree I am above the age of 18 and agree to pay any cost or charges necessary.

To prevent the spread of infectious diseases and parasites, hospitalized or boarded animals must be current on all vaccines and be free of internal and external parasites. I authorize Stone Church Animal Clinic to provide vaccine and parasite control when needed.
Signature*
Date*
Date Format: MM slash DD slash YYYY

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Payment Policy: