Sammamish Highlands Verterinary Hospital Form
  
   
Client Imformation:

Owner:______________________________
  


_________________

Last Name First Home Phone
       


_________________________________________________________________________________
Street     City             Zip Code    
           
Emergency:____________________________________________ __________________
      Place of Employment   Bus Phone
           
Spouse:______________________________
__________________
Last Name   First Home Phone
       

__________________________________________________________________________________
Street  City Zip Code
         
Emergency:____________________________________________ __________________
Place of Employment       Bus Phone
           
Referred By: Phone Book__   Location___     Friend_____________  
Name
                               
Please indicate the form of payment you wish to establish:
Visa/Mastercard__   Cash__   Check__  
 
In order to reduce bookkeeping, payments are expected at the time service is rendered. If you have a special financial need and need to establish a payment plan-please inform the receptionist prior to treatment so arrangements can be made.