Thank you for entrusting us with the care of your pet(s). So that we may be better able to meet your needs, please complete the following information:

Emergency Contact Information

Are they authorized to make medical/financial decisions on your behalf?

Are they 18 years of age or older?

Our clinic accepts Cash, Visa, MasterCard, American Express and Debit cards in addition to Care Credit and Scratchpay. We DO NOT accept personal checks. Unlike our counterparts in human medicine, we receive no financing from state or federal agencies, nor do we receive support from insurance companies or charities. It is for this reason that we require payment in full at the time services are rendered so that we can continue to operate a state of the art facility and provide your pet(s) with optimum health care. Deposits may be required for major medical/surgical cases or trauma and emergency work where hospitalization is required.

Financial Responsibility Agreement

I understand that if in the event my account becomes past due (over 30 days) a monthly Statement Handling Fee of $5 will be applied to my balance monthly and after 60 days an additional 2% service fee will be applied monthly. I understand that if my account becomes past due (over 90 days) and all attempts to arrange payment have failed, it will be turned over for collection. I also understand that I will be responsible for all applicable collection or attorney’s fees and all other costs expended to collect said amount. I also understand if in the event I pay by check* and it is returned for insufficient funds, I will be charged a fee of $35.00.


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