Surgical/ Specialist Deposit Form

Surgeon/ Specialist Deposit Form

Please submit this form 7 (seven) days prior to you pets surgical appointment.
Owner's Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Pet's Name*
I,   First Name*   Last Name*, the owner or appointed caregiver of   Patient Name*, described above have the authority to execute this consent.
I hereby authorize ABC Veterinary Hospital to collect the deposit in the amount of   Amount*. I understand that by signing this estimate, I agree to the following:

The deposit collected is to secure and schedule a surgical/ procedure date.
The deposit collected will go towards the balance of the procedure.
Should I need to cancel or reschedule, the surgeon requires a 7 (seven) day notice to be given.
The deposit is fully refundable as long as the 7 (seven) day notice has been provided.
If less than 7 (seven) days notice has been provided, the entire deposit will be forfeited and will not be returned.
I understand and agree to pay the balance in full upon check in of my pet.
The deposit collection, procedure and relevant costs have been fully explained to me, to my satisfaction.

I have read, understand and agree to accept the terms and conditions herein.
Name*

First NameLast Name
Date

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Surgeon/ Specialist Deposit Form