Name: Forrest Avenue Animal Hospital
Address: 3156 Forrest Avenue, Dover, DE, 19904, USA

Owner Full Name*
First Last
Co-Owner Full Name
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone*
Secondary Phone
Do you have an email address that you would like to share with us?*
- Yes
- No
Email address*
How did you learn of our hospital?
- Yellow Pages/Internet
- Recommendation
If recommended, who may we thank?
Pet(s) name(s)*
Authorization & Additional Charges
I am the owner or authorized agent of the pets mentioned and accept full responsibility for all costs incurred. I hereby authorize the veterinarian to examine, prescribe for, or medically treat my pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of service and the following fees will apply: Missed or Cancelled Appointment: Up to $65 (Without 24 hour notice) Returned Check Fee: $35. Monthly Statement: 1.50% of total balance I also agree to reimburse the fees for any collection agency, based on a percentage max of 40% of the debt, and all cost, expenses & attorney fees incurred in collection efforts.*
- Check here
In order to provide a safe, caring and professional environment, we require our clients to be polite and civil to our staff. Respect and common courtesy are expected while we provide service to you and your beloved pet. We reserve the right to terminate the hospital-client relationship if one is disrespectful to any of our staff members.*
- I Understand
Occasionally we will photograph our patients for educational and advertising purposes. All owner information will be kept confidential.*
- I give Forrest Avenue Animal Hospital permission to use these photographs for these purposes.
- I do NOT give Forrest Avenue Animal Hospital permission to use these photographs for these purposes.
Signature*
Date*
MM slash DD slash YYYY
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Comments
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Welcome Form

Authorization & Additional Charges

Make an appointment
with us today!

Authorization & Additional Charges

Make an appointmentwith us today!

Make an appointment
with us today!