Acquaintance Fill Out Form

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In order to more rapidly fascilitate your visit to Redmond Veterinary Clinic please fill out the form below. A
copy will await you when you arrive that will simply require your signature. If you wish, you may print a
copy of our Acquaintance Form to fill out and bring with you when you arrive for your appointment.

Contact Name:

First Name:

Last Name:

Email:

Home Phone:

Cell Phone:

Mailing Address:

City:

State:

Zip Code:

Driver's License:

Social Security:

Employed By:

Work Phone:

Present Position:

How Long Held?:

Spouses Name:

Spouse Employed By:

Spouse Work Phone:

Spouse Present Position:

Referred By:

First Name:

Last Name:

Additional Contact Person:

First Name:

Last Name:

Phone Number

The information provided is correct to the best of my knowledge. In addition I agree to the financial agreement as stated below

Agree

Decline

Financial Agreement: "The undersigned understands and agrees that any amount due for services are payable at the time of service. I understand and agree that interest in the amount of 1.5% monthly will be charged on my balance . Should any delinquent amount be placed with a collection agency for collection, I agree that an amount equal to 50% of the total bill will be added to cover any collection fees. In the event suit is filed, I will be liable for all reasonable attorney fees and court costs."

Acquaintance Form

Thank you for allowing us to Provide Uncompromised Care For Those Providing Unconditional Love.

Redmond Veterinary Clinic 1785 N. Hwy 97 Redmond, OR 97756 (541) 548-1048 Fax (541)548-2323 e-mail us | site map | Employees Only

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