Payment Agreement Plan

Payment Agreement Plan
Bergen Veterinary Hospital

1680 Teaneck Rd

Teaneck, NJ 07666

(201) 837-3470 Fax (201) 353-3400

www.Bergenvet.com
Payment Agreement Plan
I/We ____________________________________________ agree that I/we am/are indebted to Bergen Veterinary Hospital for the sum of $____________ and that I/we will pay this sum in accordance with the following terms.

I/we agree to remit the following payment(s) via Cash/ Check/ Credit Card/ Debit Card/ Money (choose one below) Order to Bergen Veterinary Hospital:
Print Name(s)*
Sum ($)*
Type of Payment*

CashCheckCredit CardDebit CardMoney Order

In any event my payment is delinquent; Bergen Veterinary Hospital will charge additional Finance and End of the Month billing charges. Finance charges will accrue from original charge date. The fees are enforced to keep administrative costs at reasonable levels preventing frequent increases in medical services fees.
Printed Electronic Signature*
Date*

MonthDayYear
Date
Should be Empty: