New Client Form Heart Of Oregon Page 2
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2Cancelled/Missed Appointment Policy:
We all have times that problems arise and cause the cancellation of an appointment at the last minute. It
happens to everyone. But if it happens more than twice or more than one appointment is missed without
notification, the full amount of that appointment will be billed to you. Clients who are more than 10
minutes late may be asked to reschedule. Please, just be considerate
□ I agree to the cancellation policy above
Media consent:
Heart of Oregon Veterinary Cardiology may publish photos of me and/or my pet for educational and
□
promotional purposes including the business website, Facebook, and/or publications.
Check to decline.
Financial Information:
Heart of Oregon Veterinary Cardiology accepts cash, check, debit cards, Visa and MasterCard for
payments. Payment is always due at the time of service. There is no billing permitted for services. If
payment is not received at the time of service there is a 10% per month billing fee, and non-payment is
sent to collections at 90 days. There is a $30 returned check fee.
By signing this statement, I signify that I agree and accept these financial conditions.
Signature: ________________________________ Date: ________________________
Applications for Care Credit and H3 Wellness Plus Cards are third party credit cards available for application.
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