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I authorize Midtown Animal Clinic to release my contact information and/or my pet’s vaccine information to the Humane Society, or other government officials. In addition, I authorize Midtown Animal Clinic to release my pet’s medical records to any veterinary facility upon request.
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I recognize that Midtown Animal Clinic requires payment in full for any and all services at the time those services are rendered.
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I recognize that in order to pay by check, I must provide a valid Driver’s License # or State ID #. In addition, I cannot pay by check for any amount over $500.00. I also recognize that if my check is returned, a $50 fee will be added to the balance on my account, I will no longer be eligible to pay by check for future services, and if payment is not promptly made, my information may be provided to the Attorney General of Arizona for failure to pay / theft of services.
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I recognize that if my account maintains an outstanding balance for 30 days or more, a 3% service charge (or $3.00, whichever is greater) will be added to the balance each month until paid in full, and my account may be suspended until paid in full. I also agree to pay for the reasonable cost of collection in the event that collection efforts become necessary - including a $35 fee for each certified letter that is sent and any fee assessed by the collection agency on behalf of my account. I recognize that my account could be sent to collections at any time.
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I recognize that in the event my pet may require hospitalization, Midtown Animal Clinic does not offer or provide 24-hour supervision/care by either a technician or a veterinarian. If my pet requires emergency veterinary care or overnight supervision, the option of being referred to an appropriate facility will be made available to me.
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I hereby authorize the veterinarian to examine, prescribe for, or treat the pets described on the previous page, and I assume responsibility for all charges incurred in the care of my pets.
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I recognize that all estimates expire 30 days after they are written. I also recognize that the final price for services may vary by as much as 30% from the estimate provided, and all prices are subject to change.
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I recognize that if I decline services, for any reason, Midtown Animal Clinic may request that I sign an “Against Medical Advice” form before releasing my pet to my care.I recognize that a $40 fee will be assessed for all “urgent/acute care” or “walk-in” appointments. I also recognize that a $20 fee will be assessed for any routine appointment that I fail to attend, or if I am ten minutes or more late for my scheduled appointment. In addition, I recognize that if I am more than ten minutes late for my appointment, my appointment will be canceled and I will be responsible for rescheduling my appointment. In addition, if I miss a SURGERY appointment, the $100 fee will apply AND I will be required to leave a $200 deposit in order to reschedule that surgery appointment.
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I recognize that Midtown Animal Clinic will neither prescribe nor refill heartworm prevention without proof of a current negative heartworm test (“current” is defined as “within the last twelve months”) or a signed AMA form.
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I recognize that Midtown Animal Clinic REQUIRES RABIES VACCINATIONS for ALL feline and canine patients. Alternatively, a valid Rabies Titer will be accepted, but must be repeated yearly to monitor titer levels and if the titer level drops below therapeutic levels, re-vaccination will be required. This requirement can be waived by a DVM, but only if appropriate medical rationale exists.
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I recognize that Midtown Animal Clinic is required by law to examine my pet prior to prescribing any medication or treatment. If the veterinarian authorizes refills of that prescription medication, those refills will no longer be available after the annual wellness exam expires. Annual wellness exams are only valid for twelve months. In addition, I recognize that “medical exams,” “surgical procedures,” and “technician appointments” do not qualify as an “annual wellness exam.” Additionally, prescription diets are considered prescriptions.
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I recognize that Midtown Animal Clinic is not obligated to notify me when a vaccination, examination, or diagnostic test is due. Electronic reminders are available, as a courtesy, but it is my sole responsibility to keep up with these reminders, and I will not hold Midtown Animal Clinic liable if I forget (or neglect) my pet’s routine vaccinations, examinations, or diagnostic testing. I also recognize that it is my sole responsibility to notify Midtown Animal Clinic in the event my contact information changes, or if my pet receives veterinary care at another facility.
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Finally, I recognize that both Coconino County and Yavapai County require licenses and proof of Rabies vaccinations for any and all dogs living in Coconino or Yavapai County. It is my responsibility to pursue licensing, and Midtown Animal Clinic will not be held liable if my dog is found to be without a license or Rabies vaccination tag.
