SA New Client Form

    Owner Information

    Second Owner Information (if applicable)

    Emergency Contact

    Pet #1

    DogCat

    Pet #2

    DogCat

    Pet #3

    DogCat

    Pet #4

    DogCat

    We do require full payment at the time of service. It is our policy that after 30 days, any discounts on the invoice will be removed, interest will begin to accrue, and a collections process will begin. In addition to cash, check or money order payments, we accept all major credit cards. We also offer help from Care Credit. This is a health care specialty company we work with who can offer assistance directly. If you are unable to pay in full at the time of service and need to arrange a payment plan, please discuss options with us before the time of service.

    I understand if I have an unpaid balance to Jackpot Veterinary Center and do not make satisfactory payment arrangements, my account may be placed with an external collection agency. I will be responsible for reimbursement of the fee of any collection agency, which may be based on a percentage at a maximum of 35% of the debt, and all costs and expenses, including reasonable collection and attorney’s fees incurred during collection efforts.

    In order for Jackpot Veterinary Center or their designated external collection agency to service my account, and where not prohibited by applicable law, I agree that Jackpot Veterinary Center and the designated external collection agency are authorized to (i) contact me by telephone at the telephone number(s) I am providing, including wireless telephone numbers, which could result in charges to me, (ii) contact me by sending text messages (message and data rates may apply) or emails, using any email address I provide and (iii) methods of contact may include using pre-recorded/artificial voice message and/or use of an automatic dialing device, as applicable. Furthermore, I consent to the designated external collection agency to share personal contact and account related information with third party vendors to communicate account related information via telephone, text, e-mail, and mail notification.