| Canyon Hills Animal Clinic PATIENT AND CLIENT INFORMATION SHEET Please print out this completed form, including the second page, and bring it to Canyon Hills Animal Clinic at the time of your appointment.
Don't forget Page 2
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Office Use Only
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Thank you for giving our hospital the opportunity to care for you and your pet. So that we may become better acquainted and maintain proper medical records as required by law, please complete the following.
Today's Date: ______/______/______
Mr. Mrs. Dr. Ms.
| Owner's | ____________ Last |
____________ First |
____________ Initial |
Spouse's________________________ |
Address_________________________ Apt.____________ City______________ State ____ Zip_________
Home Phone__________________ Work Phone__________________ Spouse Work Phone__________________
E-Mail:________________________
Place of Employment________________________ Address______________________________
Spouse's Employment________________________ Address______________________________
If Necessary, May We Call You At Work? 
Yes No
How Did You First Become Aware Of Our Hospital?
Yellow
Pages Sign
Personal
Recommendation - Whom May We Thank?____________________________________
Previous
Client Veterinarian
(Name)________________________
I Chose Your Hospital Over Others In The Area Because:
All fees are due when services are rendered. A deposit is required on all hospitalized pets and the balance is due when your pet is released from the hospital. We do not have a billing system due to the high cost involved in maintaining our hospital. You must be over eighteen years of age to authorize treatment. Please indicate your choice of payment. To pay by check, we ask that you have a driver's license. Thank You.
| Cash |
Check |
Credit
Card |
ATM |
Social Security #__________________ Driver's License #__________________ Date of Birth____________
I have read and understand your Financial Policy given to me by the receptionist. |
____________________________________ |
Thank you for giving us the opportunity to serve you.