|Social Security Number|
|Driver's License Number (required)|
|E-Mail Address (required) : |
|Payment Type (required)|
|Do you qualify for a Senior Citizens Discount (60 or older)? (required)|
|Pet's Name (required)|
|Age: Years, Months (required)|
|Type of Pet (required) : |
|Name of Former Veterinary Practice|
To expedite the first visit, please provide us with any previous medical history either by fax (518) 854-3272 or mail to Borador Animal Hospital, 4321 State Route 22, Salem, New York 12865 or bring with you to the appointment.
|Reason for Appointment|
|Special requests or conditions?|
|Scheduling an appointment|
Please call our office at (518) 854-3005 to schedule an appointment. Our rountine surgeries are scheduled on Thursdays. Farm Calls are scheduled on Mondays and Wednesdays.
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 the doctors at Borador Animal Hospital, PC and that charges are due and payable at time of service. Any balance that is carried over a period of 30 days will accrue a monthly finance and billing charge. Any balance that I leave unpaid will be forwarded to Borador Animal Hospital, PC's collection agency, and will incur a collection fee for which I am liable, in addition to monthly finance and billing charges.
|I have read this statement and - (required)|