Payment Agreement

Payment Agreement

Lake Emma Animal Hospital
I First Name Last Name agree to pay $ on each pay day of the month beginning on Date , (or other timeframe ) until the balance of $ is resolved. I understand the Account Balance Policy (briefly stated below) and consent to the terms set in this agreement.

*Payment for products and services are due within 30 days of the time of service (once your discount is applied).
*Team members will not be allowed to add to the outstanding balance for nonemergent services, payment will be due at the time of service once the discount is applied.
*If an emergency occurs and a new balance is incurred, an additional payment agreement will be required.
*If this agreement is not maintained by the team member, the employee will be at risk of losing their pet benefits due to noncompliance until balance is resolved.
I will make payments on my own based on the timing stated aboveI request paycheck deductions for the amount listed above (will make additional payments myself if amount cannot be deducted)
Signature
Date

MonthDayYear
Date
Additional Notes:
Manager's Name

First NameLast Name
Manager Approval
Date

MonthDayYear
Date
Should be Empty: