Exam Deposit Form

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patients name*

I, First Name Last Name, the owner of the appointed caregiver of Patient* , described above have the authority to execute this consent.

I hereby authorize ABC Veterinary Hospital to collect the deposit in the amount of $70.00. I understand that by signing this form, I agree to the following:
The deposit collected is to secure and schedule my first exam with ABC Veterinary Hospital.
The deposit collected will go towards the balance of the appointment.
Should I need to cancel or reschedule, ABC Veterinary Hospital requires a 24 (twenty-four) hour notice to be given.
The deposit is fully refundable as long as the 24 (twenty-four) hour notice is provided.
If less than 24 (twenty-four) hour notice is provided, the entire deposit will be forfeited and will not be refunded.
I understand and agree to pay the balance in full upon the discharge of my pet.
The deposit collection and relevant cost have been full explained to me, to my satisfaction.

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

Name*

First NameLast Name

Date*

Date

Signature*

Clear