GSVS EB client registration form

Garden State Veterinary Services East Brunswick

510 Route 18, East Brunswick, NJ 732-790-2310
Owner's Name*

First NameLast Name
Owner's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner's Cell Phone No.:*

Area CodePhone Number
Home Phone No. or Alternative Phone No.:

Area CodePhone Number
Email*
example@example.com
Spouse/Partner/Authorized Representative:

First NameLast Name
Spouse/Partner/Authorized Representative's phone no.:

Area CodePhone Number
Patient Name:*
Breed
Color and Weight (approx.):*
Species:*
If other than a dog or cat, please state what kind of animal:
Neutered:*
Sex:*
Date of Birth or Age (approx.)*
Name of Pet Insurance Co. and Policy# (if you have coverage)
If you have not already done so, please ask your veterinarian to email all medical records including radiographs to eastbrunswick@gsvs.org.
Name of Patient's Veterinarian or Veterinary Hospital and Phone # (If none, please write N/A).*
Please indicate whether you wish to have your pet's medical records released to the veterinarian you have listed on this Registration.*
I authorize the release of my pet's medical records to
CONSENT AND AUTHORIZATION

I hereby represent that I am over the age of 18 and authorize the veterinarian to examine, prescribe for or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid when the services are rendered and that a deposit will be required for treatment. Due to the nature of medical services, I understand that once a service is performed, the fee for that service is non-refundable. In the event that this account is placed with an attorney or a collection agency because of an unpaid balance remaining on my pet's account, I hereby agree and promise to pay interest of 1.5% per month of the outstanding balance to be calculated starting from my pet's last date of service. In addition, I also agree and promise to pay a collection fee of $100 or 33% of the total balance due, whichever is greater, upon placement with an attorney or collection agency because of an unpaid balance remaining on my pet's account. In the case of a returned check. I acknowledge that there will be a fee of $35 imposed by and payable to GSVS. By signing my name below I hereby acknowledge the above stated policies.
Please verify that you are human*
Date*

MonthDayYear
Date
Signature*

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Garden State Veterinary Services East Brunswick