CLIENT INFORMATION

客户档案

TODAY’S DATE 今日日期:

YY年________ MM月______DD日_____Patient file no.: ________________

LAST NAME姓___________________________________FIRST NAME名________________________________

SIGNIFICANT OTHER’S NAME配偶的名字________________________________________________________

HOME ADDRESS (Street) 住址____________________________________________________________________

CITY市_______________________________________PROVINCE省____________________________________

COUNTRY国家________________________________ZIP CODE邮编___________________________________

HOME NUMBER 家庭电话(____)________________WORK NUMBER办公电话(____)____________________

MOBILE手机_________________________________FAX NUMBER 传真(_____)_________________________

E-MAIL 电子邮箱______________________________________________________________________________

MAY WE CALL YOU WHEN YOU ARE IN THE OFFICE? □YES 可以 □NO 不可以

（在您办公期间，我们能否打电话?）

OCCUPATION 职业_________________________COMPANY NAME 公司名称___________________________

We appreciate your choosing ICVS. How did you hear about us? ____________________________________________

我们很感谢您的选择. 您是怎样了解到我们的？

□Friend/Family 朋友/亲戚□Poster/flyer 宣传单□Magazine 杂志□Word-of-mouth 听说

□ICVS staff (please indicate name) 北京新天地国际动物医院员工(请指出员工名字) _________________________

How do you prefer to pay? 您的付款方式□Cash现金□Credit Card信用卡□Debit Card借记卡

NOTE: Professional fees are due at the time that services are rendered. Prepayment based upon estimate required for hospitalization. Any additional balance will be due upon pick-up.

注释：服务结束后付相关的费用。住院需预付。其他附加费用在领取宠物时支付。

The International Center for Veterinary Services is committed to providing the highest quality of veterinary medicine. Thank you for letting us serve you and your furry friends!

新天地国际动物医院，将会提供最高的医疗技术。谢谢您允许我们为您和您的宠物服务！

CLIENT SIGNATURE签名________________________________________DATE (MM/DD/YY)________________