Beaumont Small Animal Clinic

1304 N Cunningham Ave
Urbana, IL 61802

(217)367-1187

www.beaumontanimalclinic.com

New Client Form

You can expedite your check in by submitting this form prior to your first visit. Thank you for giving us the opportunity to care for your pet!

New Client (BAC)

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,		State / Province (required)
Zip / Postal Code (required)
Client's Birthday (required)

Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone 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


Special requests or conditions?

Please list any additional pets here

Selection :
How did you hear about us? (required) :
If referred by a friend, please tell us their name.
Referral Name
First Name
Last Name
Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of Beaumont Small Animal Clinic PC 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 incurred to collect this debt. This includes, unless prohibited by law, all reasonable attorney 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 -

I Agree
I Disagree



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