New Client Form for Cat Clinic of Iowa

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Cat Clinic in Iowa City, IA

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Owner's Name *

First

Last

Spouse / Significant Other Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Work Phone

Cell Phone *

Email *

Preferred contact method *

Home Phone
Work Phone
Cell Phone
Email

Employers Name *

Employers Address *

Address Line 1

Address Line 2

City

State

Zip Code

Preferred Method of Payment : *

Cash
Check
Credit Card

Name of Previous/Current Veterinarian *

Please select one *

I am transferring care to your clinic.
I would like records faxed to my current veterinarian

How did you hear of our hospital? *

Individual
Yellow Pages, or another telephone directory?
Hospital Sign / Drive-By?
Internet

Payment is due in full at the time that services are performed. We accept Cash, Visa, MasterCard, Discover, American Express, and CareCredit payments. We neither extend credit, nor bill for services. All open invoices are sent to collections after 180daysunless prior arrangements are made. *

I have read and accept the financial policy.

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Cat Clinic of Iowa City proudly serves the cats of Cedar Rapids, Marion, North Liberty, Tiffin, West Branch, West Liberty, Hills, Riverside, Kalona, and beyond. We look forward to seeing you and your cat soon!

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