3449 Deltona Blvd.
Spring Hill, FL  34606
(352) 686-0671

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Client Information Sheet

Animal Medical Clinic
3449 Deltona Boulevard
Spring Hill, FL 34606
Welcome to the Animal Medical Clinic! 

First Name:
Last Name:
Spouse:
Address Street 1:
City:
State:
Zip Code: (5 digits)
Home Phone:
Cell Phone:
Work Phone:
Employer:
Email:
Driver's License No.:
SS#:  (Requested, not required)
How did you first hear about us?:
   Please tell us about your pet:
Pet's name:
Type of pet? DogCatBirdOther
Breed:
Color:
Neutered?  YesNo
 Sex:
 MaleFemale
Birth date (or estimated age of pet):
Prescription medicines:
Signature of Owner:
Please click the box below to authorize treatment of your pet. Thank you.
  I hereby authorize the staff of the Animal Medical Clinic to examine and treat the above described animal. I understand that payment for serices rendered is required at the time the animal is discharged from the clinic
How will you be paying today? MC/VISAAMX/DSCCHECKCASHDEBIT
  Please note our Financial Policy below.

Financial Policy
ALL PAYMENTS ARE DUE AT TIME OF SERVICE, WE DO NOT DO PAYMENT PLANS OR TAKE POST DATED CHECKS.

Personal Checks: The Animal Medical Clinic reserves the right to refuse a personal check from any new client.

Returned Checks: There will be a fee (currently $20.00) for any returned checks returned by the Bank.  If payment is not received on a returned check, we have the right to refuse future services and/or request alternative payment method.
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