Dr Emilio Bustillo Online Registration Form

Owner/Patient Registration

Thank you for giving us the opportunity to care for your pet(s). Please complete ALL information.

Last Name:

First Name:

Middle Name:

Address:

City:

State:

Zip:

Driver's License #:

Home Phone:

Email:

Cell Phone:

Work Phone:

Employer:

How did your first hear about our service?

Hospital Sign:

Yellow Pages:

Prior Client:

Internet:

Other:

Pet's Name:

Species: - Feline Canine

Breed:

Color(s):

Birth date / age:

Sex: - Male Female Neutered (Male) Spayed (Female)

Previous Doctor's Name / Animal Clinic:

Previous Medical History / Vaccines:

Pet's Name:

Species: - Feline Canine

Breed:

Color(s):

Birth date / age:

Sex: - Male Female Neutered (Male) Spayed (Female)

Previous Doctor's Name / Animal Clinic:

Previous Medical History / Vaccines:

SORRY, WE DO NOT ACCEPT CHECKS! We accept cash and major credit cards.
All fees are due at the time that the patient is released. On your request, we will provide you with a written estimate of fees for any case: hospital treatment, emergency care, surgery or hospitalization. A DEPOSIT IS REQUIRED prior to treatment. I hereby agree that should this account be referred to an agency or attorney for collection, I will be responsible for all collection cost, attorney's fees and court cost. If not give 24 hrs notice of appt cancellation, a US$ 45 charge will be charged to your credit card on file. We are dependent upon your fees to maintain our high quality of patient care. The Hospital does not extend credit (bill) and you are responsible for all fees and products for services rendered. There is an urgent emergency fee of US$ 175.00 for pets without appointment. A deposit will be required prior to initial treatment and you authorize us to bill your credit card for any balance remaining. A US$ 200.00 deposit is required for house-calls, a 24 hours cancellation notice must be given for full reimbursement. Dr. Bustillo is a Miami veterinarian.

I agree to the above terms & conditions.

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