New Client Form | Westside Veterinary Clinic in Florence, SC

Welcome!

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WESTSIDE VETERINARY CLINIC, P.C. Welcome to Westside Veterinary Clinic Thank you for choosing us for your pet’s healthcare.

Client Information

Name:(Required)

Co-Owner:

Address(Required)

Street Address Apt.# City State / Province / Region ZIP / Postal Code

Telephone Numbers/Contact Details

Home:(Required)

Work:

Cell:

Co-Owners#:

Email:

Emergency Contact Name and Number:

How did you hear about us?

FINANCIAL INFORMATION

PAYMENT IS DUE AT TIME OF SERVICE.

Initial(Required)

Methods of payment: We accept most major credit cards and debit cards with a 3% charge. We also accept care credit. We accept local personal checks. A valid photo I.D. (must be SC State issued for checks); working phone number and address may be required for any payment method other than cash.

Initial(Required)

Deposits: A deposit will be required for procedures exceeding $400.00. Equal to at least half of the estimate given for treatment to be paid at the beginning of treatment, with the remainder of the balance to be paid when the pet is checked out of the hospital. Please note that lengthy hospital stays or treatments that go well beyond the original estimate may require additional payment during the pet’s stay. I hereby authorize the staff of Westside Veterinary Clinic, P.C. to examine and treat my pet(s). I assume all financial responsibility for all authorized care including care authorized by my agents. I understand all the policies and financial information given to me. I understand it is my responsibility to discuss any concerns that I may have in regard to treatment and/or financial situations before treatment begins. I understand that I may ask for a written estimate at any time if one is not provided to me.

CLIENT SIGNATURE(Required)

DATE

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