Enrollment Form | Institute of Veterinary Specialists

Clinic Name:

Legal business name (If Different):

Shipping Address

Address Line 1

Address Line 2

City

State

Zip Code

Billing Address

Check if same as shipping

Address Line 1

Address Line 2

City

State

Zip Code

Phone:

Fax:

How would you like your reports/ statements delivered?

Preop/Screening: Verbal results with:

e-mailed report
faxed report
no written report
both e-mailed and faxed

Full Reports (Phone/ STAT/ Code Red): Verbal results with:

e-mailed report
faxed report
both e-mailed and faxed

Statements:

e-mailed
sent via USPS

Clinic e-mail:

Manager/Acct Contact name:

Doctor's Name(s):

Owner/Principal's Name:

Social Sec #:

Home Address:

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone:

How did you hear about us?

Billing Options (choose one):

I prefer to be billed monthly* (Social Security Number Required for Credit Purposes)
I prefer to have my credit card automatically debited monthly (Please fill out below.)

Credit Card Information:

Visa
Mastercard
Discover

Card Number:

Exp. Date:

3-digit verification code:

Name On Account:

Billing Address of Credit Card:

Address Line 1

Address Line 2

City

State

Zip Code

Do you own an ECG Transmitter?

Yes (describe below)
No
No, I am interested in purchasing one

Please describe what type of ECG Transmitter you currently use

Terms are payable upon receipt. Finance charges of 1.5% per month (18% Annual) will be assessed on any balance unpaid after 30 days. Past due accounts are subject to credit restrictions and credit holds. Payment may be made by business check, Visa, MasterCard and Discover. There is a returned check fee of $25.00. By signing this agreement, I personally consent to pay any outstanding debt, including collection and/or any reasonable legal fees. I have provided the correct information above and I agree to the terms and conditions contained herein.

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Online Enrollment Form

Online Enrollment Form for Veterinarians