This is an agreement between Plymouth Veterinary Clinic, as creditor, and the patient/debtor named on this form. In this agreement, the words “you”, “your” and “yours” mean the patient/debtor. The word account means the account that has been established in your name to which charges are made and payments credited. The words, “we”, “us” and “our” refer to Plymouth Veterinary Clinic. By executing this agreement, you are agreeing to pay for all services that are received.
Client Sheet: You are required to have a current client sheet on file with the clinic. Charging privileges will not be extended if you fail to complete the sheet, refuse to provide requested information, or sign the agreement.
Payments: Unless other arrangements are approved by us, in writing, the account balance on your statement is due and payable when the statement is issued. Clients who have had continuous service for one year will be considered for payment arrangements for services rendered as a last resort. Care credit/Scratch Pay must be applied for before any payment arrangements will be considered. If a DVM sees a payment plan/recurring billing fit for you, there must be a credit/debit card left on file. There will be a $25 convenience fee applied to all payments plans.
Monthly statement/finance charge: Any account with a balance over 30 days old will have a finance charge of 2% per month or an annual percentage rate of 24%. The finance charge on your account is computed by applying the periodic rate (2%) to the overdue balance of your account. The “overdue balance” of your account is calculated by taking the balance owed thirty (30) days ago and subtracting any payments or credits applied to the account during that time. A monthly statement will then be sent via regular mail. To keep account in good standing, payment must be made every 30 days and balance should be paid in full within 6 months of the date services were rendered.
Past due accounts: If your account becomes past due, we will take necessary steps to collect this debt. If we must refer your account to a collection agency, you agree to pay all the collection costs which are incurred. If we must refer collection of the balance to an attorney, you agree to pay all attorney fees which we incur, plus all court costs. In case of suit, you agree the venue shall be Marshall County, Indiana. In addition to collecting the due debt, you will no longer be allowed charging privileges.
Charges to Account: ALL medications and products must be paid for before leaving the building. Charging medication/products is not allowed.
Charging to another client’s account: Services cannot be charged to another account unless the account holder agrees, in writing, to accept responsibility for the account in the event of default.
Returned medications: Medications that are returned can only be credited IF they are individually wrapped. Meds dispensed in bottles can only be returned as a donation, no credit to be issued.
Insurance payments: Any services covered by an insurance policy must be paid at the time of service. You can then be reimbursed by your insurance company.
Divorce: In the case of divorce or separation, the party responsible to the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, the client authorizing treatment for the pet will be responsible for those subsequent charges. If the divorce decree requires the other client to pay all or part of the treatment costs, it is the authorizing client’s responsibility to collect from the other client.
Waiver of confidentiality: You understand, if this account is submitted to an attorney or collection agency, if we must litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you have received treatment at our office may become a matter of public record.
Returned checks: There is a $25 fee for any checks returned by the bank. No Show Policy: Patients who fail to show for their scheduled appointment or do not notify the clinic within 24 hours of the appointment time, will be subject to a "No Show" fee of $50.00. This fee will be due prior to the next in clinic visit
Effective date: Once you have signed this agreement, you agree to all the terms and conditions contained herein and the agreement will be in full force and effect.