New Client Form (Page 2 of 2) in pdf

New Client Form Page 2

PAYMENT

ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENEDERED.

WE WILL PREPARE A WRITTEN ESTIMATE IF YOU DESIRE. PLEASE ASK A MEMBER OF OUR HEALTH-

CARE TEAM. FOR YOUR CONVENIENCE WE TAKE PERSONAL CHECKS, VISA, MASTERCARD, DISCOVER,

AMERICAN EXPRESS, DEBIT AND CARE CREDIT.

THERE WILL BE A $30.00 SERVICE CHARGE FOR ANY CHECK RETURNED UNPAID.

TO PREVENT THE SPREAD OF INFECTIOUS DISEASES, ALL HOSPITALIZED AND BOARDED PATIENTS

MUST BE CURRENT ON ALL VACCINES AND FREE FROM INTERNAL AND EXTERNAL PARASITES. BY

CLICKING ON THE SUBMIT BUTTON BELOW, YOU AUTHORIZE THIS LEVEL OF PREVENTIVE CARE AND

YOU AGREE TO PAY THE APPROPRIATE CHARGES ASSESSED IN THE DISCHARGE INVOICE.

BY SUBMITTING THIS ONLINE FORM, I CERTIFY I AM THE OWNER OF THIS/THESE PET(S) AND I AGREE

TO BE RESPONSIBLE FOR AUTHORIZING PROCEDURES AND/OR PAYING FOR SERVICES.

New Client Form Page 2