1st Time Visitors Form

Owner Information Form
City
State/Province
Zip/Postal

Patient Information

Please Note:
• Cash/credit card/check payment is due at the time of patient discharge
• A deposit (20% of estimate) is required on all hospitalized patients
• Owner/agent agrees to pay all costs of collection, including a reasonable attorney’s fee and 1½ % per month (18% APR) on all unpaid balances
Sending