Client Information

Name *

First

Last

Spouses Name

Date *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Work Phone

Place of Employment *

Cell Phone

Email *

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Driver’s License Number (please specify state if other than Texas) and Date of Birth of person responsible for bill

(TX)

Date of Birth

Patient Information

Pet Name *

Species *

Breed *

Color *

DOB or Approximate age *

Gender *

Pet Name

Species

Breed

Color

DOB or Approximate age

Gender

How will you be paying for the services ? (Please check one)

Lazy 3 Animal Care Inc. Payment and Collection Policy: We do appreciate you allowing us to care for your animals. We take great pride in making this a pleasant experience for you and your pet(s). Unfortunately due to complications collecting payment there will be absolutely no Held Checks. Products and services must be paid for when rendered. We do ask that all account balances be paid in full at the time of service. If extensive treatment is needed on your pet due to unforeseen circumstances and cost is a concern, please talk to the Doctor about payment at time of examination. At that time, you and the doctor can discuss and agree upon the terms of payment. These terms of payment will be put in writing and you will be held accountable by a court of law if you become delinquent on your account. Additional costs will include existing account balance, all interest accrued on account ( 1.5%) , all legal fees, and collection fees. *

I have read and understand Lazy 3 Animal Care Inc. Payment and Collection policy

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