Company Owner's Name * Co-Owner Email * Street Address * City * State * Zip Code * Receive emails for pet health updates, reminders, & clinic news? Yes No How did you hear about us? * Friend/Family Google Search Other Other Online Search Other Website Pet Store/Suppy Store Sign/Location Yahoo Yelp Contact Phone Number * Additonal Contact Number Would you like information about any of the following services? Acupuncture Dentistry Diets: Alternative Grain Diets: Grain Free Diets: Home Cooked Diets: RAW Flower Essences Herbal Medicine Holistic Medicine Homeopathy Joint/Arthritis Support Microchipping Pet Insurance Senior Pet Health Skin/Coat Supplements Vaccine Alternatives Wellness Plans How many pets * 1234 Pet's Name * Breed * DOB or Approx * Color * Sex * Female Male Spayed/Neutered * Yes No Major Illnesses, Injuries or Diagnosis Previous Vet/Clinic and Number I agree to the terms listed below * Yes Conditions I AGREE TO PAY FOR PROFESSIONAL SERVICES, MEDICATIONS & INVENTORY AS THEY ARE RENDERED. I understand every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care and handling. I hereby authorize this hospital to receive, prescribe for, treat or perform surgery upon the pet(s) listed on this page(s), as deemed necessary when in the care of Belleview Animal Clinic. Furthermore, I agree to pay fees for services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated. In the event your account is assigned to a collection agency, you agree to pay a collection fee in the amount equal to 35% of the balance due assigned to the collection agency. In case of default payment, I agree to pay any and all costs of collecting this account including, but not limited to, attorney fees and court costs.