Pig Client Registration

Client's Name *

First

Last

Email *

Billing Address *

Line 1

Line 2

City

State

Zip Code

Country

Business / Farm Name *

Premise ID *

Farm / Shipping Address *

Line 1

Line 2

City

State

Zip Code

Country

Contact Phone Numbers
Please identify each number

Primary Phone Number *

Primary Contact name *

Choose One *

Cell Home Work

Secondary Phone Number *

Contact Name *

Choose One *

Cell Home Work

Alternate Phone Number *

Contact Name *

Choose One *

Cell Home Work

Authorization & Payment responsibility Notice

I hereby authorize the veterinarian to examine, prescribe for, or treat my animals. In consideration of the services provided to the animals, I/we understand and agree that I/we are financially responsible for payment of all services rendered. I/we understand and agree that any remaining balance on accountnot paid in full within 30 days will acrue a monthly finance charge of 1.5% (minimum $4.50).

We offer two methods of billing for our pig clients as most of these services are performed at a location and/or time outside of our regular office hours.
Monthly Statements: Payment is due in full within 30 days of receipt. Account charges are closed on the last day of every month and paper statements mailed out.
Automatic Payments: Account balance will be paid in full with a credit card kept on file. The credit card will be processed on a predetermined date. Please download and complete the Auto Pay Authorization form and email it to info@tlcpethospital.com.