• VILLAGE CROSSROAD ANIMAL HOSPITAL

    NEW PATIENT FORM
  • Referral

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  • PAYMENT POLICY:  All fees and charges are due and payable upon release of patient unless prior arrangements have been made.  Any balance forward is subject to monthly statement handling fees as well as service finance charges.

    PAYMENT AGREEMENT: I am the owner or agent for the owner of the above described pet and have the authority to execute treatment agreed upon by myself and the attending veterinarian.  As the owner or agent for the owner, I understand it is my responsiblity to remit payment for treatments performed.

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