Let’s Get Acquainted – Bannock Animal Medical Center

Spouses Employer

Nearest Relative or Friend

Nearest Relative or Friend phone number:

In signing I, {FirstName}, understand that I am responsible for all fees incurred at Bannock Animal Medical Center, and that I am the owner, or representative of the owner, for each pet listed. I give permission to Bannock Animal Medical Center to transmit my pets’ entire medical records to other veterinarians who have given my pet care, or to whom I may take my pet in the future for care, upon their verbal request. I have received and read the Financial policy for BAMC.

I understand that should collection become necessary, as the responsible party, I agree to pay an additional $25 collection fee and all legal fees associated with the collection process, with and without suit, including attorneys’ fees and court costs.

All fees are due when services are rendered.(Signature)

How do you prefer paying your bill? (We are sorry but we do not accept checks)

CASHVISA/MC/ DISCOVERCARECREDIT (RequiresApplication)

How did you find out about Bannock Animal Medical Center?

Personal Referral name

Were you offered a tour of our facility?

YesNo

Pet's Name

Species

Sex

Microchip?

NEUTERED/SPAYED:

Pet Birth Date:

Breed

Color

What medications does your pet take regularly?

KNOWN ALLERGIES:

Do want add additional pets?(add 2nd Pet)