"*" indicates required fields Animal Care Hospital Thank you for entrusting the care of your animal(s) to ACH. So that we can better serve you please complete the following: Client InformationYour Name* First Last Pet Name*Home Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mobile Phone*Your EmployerWork PhoneEmail Address* Driver's LicenseExpirationSpouse / Other OwnerNameEmployerMobile PhoneWork PhoneOther Legal Agents of Your AnimalsEmergency ContactSomeone not living with youNamePhoneWhom May We Thank For Referring You?* Fayette Falcon Horse Review Website Social Media (Facebook, etc) Drive-By Yellow Pages Online Welcome Letter Yellow Pages Book Individual Individual Name:*PAYMENT* Please read and confirm your understanding by checking the checkbox.ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. WE WILL GLADLY PREPARE A WRITTEN TREATMENT ESTIMATE. CASH, CHECK, OR CREDIT CARDS ARE ACCEPTED. THERE WILL BE A $20.00 DOLLAR SERVICE CHARGE FOR ALL RETURNED CHECKS. I ASSUME RESPONSIBILITY FOR ALL CHARGES INCURRED DURING THE CARE OF MY PET(S)/ANIMAL(S) AND UNDERSTAND THAT VETERINARY TREATMENT DOES NOT GUARANTEE A SUCESSFUL OUTCOME OR CURE. I AGREE THAT IF THIS ACCOUNT IS PLACED INTO THE HANDS OF AN AGENCY OR ATTORNEY FOR COLLECTION, BY SUIT OR OTHERWISE, I WILL PAY ALL COSTS OF COLLECTION, LITIGATION, AND ATTORNEY’S FEES. I ALSO UNDERSTAND THAT THERE IS A 21% ANNUAL SERVICE CHARGE ON ALL ACCOUNTS OVER 30 DAYS, WITH A 2% MINIMUM MONTHLY SERVICE CHARGE. IF MY ACCOUNT GOES OVER 90 DAYS IT WILL BE TURNED OVER TO A COLLECTION AGENCY. TO PREVENT THE SPREAD OF INFECTIOUS DISEASES & PARASITES, ALL HOSPITALIZED AND BOARDING PETS MUST BE CURRENT ON ALL VACCINATIONS AND FREE OF INTERNAL & EXTERNAL PARASITES. I AUTHORIZE ANIMAL CARE HOSPITAL TO PROVIDE IMMUNIZATIONS AND PARASITE CONTROL AS NEEDED FOR MY PET(S). I UNDERSTAND THAT EQUIDS AND LIVESTOCK ARE INHERENTLY DANGEROUS ANIMALS AND THAT ANIMAL CARE HOSPITAL ASSUMES NO RESPONSIBILITY FOR ACCIDENTAL ILLNESS, INJURY, OR DEATH TO ANIMALS, OWNERS/AGENTS, OR OBSERVERS, DURING, OR AS A RESULT OF, VETERINARY TREATMENT. THE SIGNATURE BELOW INDICATES ACKNOWLEDGEMENT & UNDERSTANDING OF THE ABOVE TERMS.Signature of Owner or Agent*Date* MM slash DD slash YYYY