New Client for Country View Veterinary Clinic

Country View Veterinary Clinic

2619 West Springfield Avenue
Champaign, IL 61821

(217)356-6481

www.countryviewvetclinic.com

New Client Check In

You can expedite your check in by submitting this form prior to your first visit.

New Client (CVVC)

Name (required)

First Name (required)	Last Name (required)

Address (required)
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

Daytime Phone (required)
Phone Type	Phone Number (required)

Evening Phone (required)
Phone Type	Phone Number (required)

E-Mail Address :

Pet's Name (required)

Age: Years, Months

Type of Pet (required) :

Breed:

Color:

Sex: (required)

Male
Female

Neutered/Spayed

Neutered
Spayed

Please check if we have your permission to post your pet's picture on our Facebook page?

Special requests or conditions?

Please list any additional pets here

Which clinic is this for? (required) :

How did you hear about us? (required) :

If referred by a friend, please tell us their name so we may thank them.

Referral Name

First Name	Last Name

Please Read
By indicating I agree and submitting this registration, I am responsible for any charges incurred by my pet while in the care of Country View Veterinary Clinic and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. I agree to pay all reasonable costs you incur to collect this debt. This includes, unless prohibited by law, all reasonable attorney?s fees, filing fees, court costs, collection agency costs, service fees, and other related collection costs or contingencies. I understand that if any unpaid balance is turned over to a collection agency that a fee ranging from 30%-50% will be added to the total balance due. I hereby give you or any of your agents or assignees to whom you turnover any unpaid balance permission to obtain a report from a credit reporting agency and to take reasonable steps to verify my credit and or employment information. I give you or any of your agents or assignees to whom you turnover any unpaid balance to contact me regarding this transaction or any future transaction at any telephone numbers of which they are aware including cellular telephones by manually dialing, using an auto-dialer or pre-recorded message.

I have read this statement and - (required)

I Agree
I Disagree

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