Home | Services | About Us | Contact | Forms | Client Education | Newsletters | Wellness Program | Directions

Forms: Client Information Form

©2008 Copyright Deer Creek Equine Clinic. All rights reserved

Please fill out the information below completely and accurately. All records are kept confidential. In the future, if anything changes, please all the office so we can update our records.

Name:
Address:
E-mail:	(for announcements and newsletters)
Phone:	Work:
Cell:	Barn:
If mailing address is a post office box, please list physical address below:
Street:
City:	State:       Zip:
Employer:
Employer's Address:
Emergency Contact Name:       Phone:
Address:
Relationship:

• Payment of fees is due at the time of veterinary service. We accept payments in cash, check, VISA, MasterCard, Discover and American Express. (Automatic credit card payment forms are available)
• Returned Checks - A fee of $ 35.00 is charged for each check returned for non-payment.
• Retail Sales - Any customer pickups should be paid at the time of the pickup.
• All clients less than 18 years of age, must have their parent or guardian take full responsibility of the account with the account in the parent or guardian's name.
• Finance charges of 1.5% are required on all balances over 30 days past due. These rates are subject to change due to changes in economic conditions.
• Any collection costs incurred by the clinic including reasonable attorney and collection fees will be added to the clients balance and paid by the client.