I hereby authorize the veterinarians of Atlantic Veterinary Hospital to examine, treat, and prescribe for my pet, described above.
I understand the following:
- I certify that I am at least 18 years old and the legal owner or guardian of the pet(s) described below.
- I am responsible for all charges involved in the care of my pet(s) and agree to make payment in full at the time of service. I will pay by cash, check, Visa, MasterCard, or Discovery.
- At my request, a Treatment Plan with the estimated cost for care will be provided for my approval.
- I may request complimentary assistance in completing pet insurance refund claims; however, I am responsible for the relationship with my pet insurance company.
- A $35 fee will be charged on all returned checks; a fee of $3 plus an interest charge of 1.5% will be added each month to all outstanding balances older than 30 days; and if my account is more than 90 days past due, I understand that my information will be submitted to a bill collection agency, which may adversely affect my credit rating.
- Just as I expect to be treated with respect and kindness, I agree to treat the staff and doctors of Atlantic Veterinary Hospital with civility and respect at all times.