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Action Care Mobile Veterinary Clinic, LLC
Mechanicsville, Maryland
301-884-PETS (7387)

Client Registration

Name: Mr.,Mrs.,Miss, Dr. ________________________________________________ Date:___________________

Driverís License or I. D. Card Number: _______________________ Expiration date:______________________

Social security #______________________________________

Address: ______________________________________________________________________________________
                Street number and name                           City                     State                     Zip Code

Occupation: _______________________ Employer: _________________________________________________

Spouse [  ]  Partner [  ] Co-owner [  ]  Name: ______________________________________________________

Telephone:

Home: ____________________________Work:________________________ Cell:__________________________

How did you hear about us?  ____________________________________________________________________

If referral, whom may we thank? ________________________________________________________________

Reason for leaving previous veterinarian: ________________________________________________________

Email Address: ________________________________________________________________________________


PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE PERFORMED

  • In admitting my pet(s) for diagnostics, treatment, or surgery, I authorize the veterinarians of Action Care Mobile Veterinary Clinic, LLC, and their support staff, to administer such treatment and/or perform such diagnostic or surgical procedures as deemed necessary.
  • It is understood that an estimate of charges will be given for services.  No guarantee or assurance can be made as to the results that may be obtained.
  • Further, I understand that a deposit of at least 50% is required before services are performed and all final charges must be paid at time of discharge.  I assume full financial responsibility for all charges incurred by my pet.  I realize that these charges may exceed a given estimate if complications arise.  I understand that I will be contacted prior to treatment, if possible, should complications occur.
     

No billing or credit is available through our service.  Please indicate your choice of payment:


Check [   ] Cash [   ] MC/Visa [   ] Other: ________________


Signature: ______________________________________________________  Date:_______________________