• Owner Information

  • Authorized Representative If Owner Not Present

  • Patient Information

  • Consent And Acknowledgement Statement

    I hereby declare that I am over the age of 18 and have the authority to present the above described pet for veterinary care. I consent to the veterinarian examining, treating, and prescribing for the above men-tioned pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges are to be paid at the time of services rendered. Due to the nature of these services, I under-stand that once a service is performed the fee for that service is non-refundable. In the event of non-payment I promise to pay an additional $3 billing fee per month and an additional 1.5% service fee on the standing balance per month. I acknowledge that there will be a $30 fee applied to any returned check.
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