The Cat Hospital of Durham and Chapel Hill

The Triangle's First Feline Exclusive Hospital
5319 New Hope Commons Drive, Suite 102B
Durham, NC 27707 
ph (919) 489-5142
fax (919) 493-4600

The Cat Hospital of Durham and Chapel Hill
M - F: 8am-6pm
Sat: 8:30am-12pm
Sun: closed
After hours emergencies: call  (919) 489-0615
Copyright 2010 -  The Cat Hospital of Durham and Chapel Hill

Form - New Client Information

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Primary Phone (required)
Phone TypePhone Number (required)
Additional Information
Phone TypePhone Number
E-Mail Address :
Recieve paperless reminders via email (required)
yes
no
Employer
Employer

Work Phone
Phone TypePhone Number
Which phone number is the best way to reach you? (required)
(best phone number)
cell
home
work

Co-Owner/Spouse Name
First Name
Last Name
Co-Owner/Spouse Phone
Phone TypePhone Number
Co-Owner/Spouse Employer
Co-Owner/Spouse Employer

Co-Owner/Spouse Work Phone
Phone TypePhone Number
How did you hear about us?
Personal reference
phone book
internet
other

Important Payment Information and Privacy Policy
Payment Information
Full payment is required for all services rendered. WE DO NOT BILL. A service fee of $30.00 will be assessed for all returned checks. Any unpaid balance on the account by the end of the month will incur a service charge of 1.5% per month (18.0%) and an account handling fee of $5.00 per month. Any account with an unpaid balance after 90 days will be referred to a professional collection agency.
Privacy Policy
The Cat Hospital of Durham and Chapel Hill does not share client or patient information with any third party unless we are listed as a reference or the information is required by law enforcement/animal control. Being listed as a reference will be considered consent to release medical records to the party requesting the reference.
I have read the Payment Information and Privacy Policy

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