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Owner's Name
Address
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Preferred Contact Method
IN AN EMERGENCY, IF WE CAN’T REACH YOU, WHO IS A THIRD PARTY WE CAN CALL?
PAYMENT IS REQUIRED AT TIME OF SERVICE:
OR
In order to help keep costs down and to continue to provide the highest quality of veterinary medicine, we require payment in full at the time services are rendered. For your convenience we do accept Cash, Visa, Mastercard, Care Credit and Checks (with appropriate I.D.) If for any reason a portion of the balance remains unpaid at the time of service, the client agrees to pay a five-dollar processing fee that will be assessed monthly in addition to 1.5% interest on balances older than 30 days. In the event that a client defaults on payment, the client also agrees to pay all costs (including but not limited to collection and/or reasonable attorney’s fees, court costs and any other fees or costs that occur during normal collection procedures).
Clear Signature
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