New Client Registration Form

Owner Information

Street Address:
City:	State: Zip Code:

Owner's Employer:
Employer's Address:
City:	State: Zip Code:

Home Phone (with area code):
Work Phone (with area code):
Cell Phone (with area code):

E-mail Address:

Pet Information

First Pet

Second Pet

Third Pet

Other Informtion

How did you hear about Dale City Animal Hospital? Please check all that apply.
Money Mailer
Phone Book
Crosspoint Chronicle
South County Chronicle
Military Directory
Red Community Phone Book
Dale City Animal Hospital Website
The Connection Newspapers
Friend or relative (If so, who?: )
Other (Please specify: )

Please read the following and respond:

I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Dale City Animal Hospital, and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.75% or 21% per annum. Any balance that I leave unpaid will be forwarded to Dale City Animal Hospital's collection agency, and will incur a 30% collection fee for which I am liable, in addition to monthly finance charges.

I have read this statement and

I agree I do not agree

with its stipulations.

If there is anything else you would like to tell us, please enter your comments here: