New Client Waiting List Form New Client Waiting List We require a $35 non-refundable down payment to go toward your visit in order to hold your appointment time. Owner's Name * Owner's Name First First Last Last Email * Home Phone * Cell Phone Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Owner's Birthdate * Employer's Name Employer's Phone * Employer's Address * Employer's Address Employer's Address Employer's Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Spouse's Name Spouse's Name First First Last Last Cell Phone Work Phone Spouse's Birthdate Spouse's Employer's Name Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Pet Information Pet Name * Species * Breed * Gender * Female Female-spayed Male Male-neutered Color * Birthdate * plus1 Add another Pet minus1 Remove a Pet General Availability * Type of Appointment Requested How did you hear about us? * - Select One -WebsiteYellow PagesOnline SearchReferred ByOther How did you hear about us? Referred by PAYMENT IS DUE AT THE TIME OF SERVICEBe advised, payment is due at time of service. We require a $35 non-refundable down payment to go toward your visit once we schedule your appointment to hold that time. If you do not show for your appointment, or cancel same day, you will forfeit that $35. We cannot accept Care Credit over the phone to charge your down payment, however, we do accept Care Credit in person at your appointment. Multiple forms of identification are required by the cardholder when using Care Credit. FINANCIAL RESPONSIBILITY AGREEMENT:I understand that I am responsible for all charges for the care of my pet(s) provided by Warrick Veterinary Clinics. I understand a finance charge of 1.75% monthly, (21% Annual Percentage Rate) will be charged on any past due balance should the account become 30 days delinquent. I understand that if any unpaid balance is assigned to a third party collection agency for collection or placed with an attorney to obtain judgement or otherwise satisfy payment of my account a collection fee of 33 1/3% will be added to my account. I agree to pay that fee. I further agree to pay reasonable attorney fees and court costs. I understand and agree to the terms above. DISCLAIMER: By typing your name below, you agree that your electronic signature is the legal equivalent of your manual signature on this form. Signature * signature keyboard Clear Date * Captcha Submit If you are human, leave this field blank.
