Street Address Line 2
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PROFESSIONAL FEES ARE TO BE PAID AT THE TIME THEY ARE RENDERED. PLEASE CHECK YOUR PREFERRED METHOD OF PAYMENT.
Any Medication? (If so please list:
What do you feed your pet?
Previous Medical Problems:
I fully understand and agree that all fees are due upon services rendered by Lebanon Animal Hospital. I fully understand and agree that any payment that is declined, cancelled and/or returned, shall be paid in full by me within twenty four (24) hours and I agree that I will be charged an additional $30.00 for any declined cancelled or returned payment. I hereby understand and agree that should I fail to pay the amount due for services rendered for any reason whatsoever, I will be responsible for any and all reasonable attorney’s fees, expenses and court cost involved in the collection of any fees due Lebanon Animal Hospital.
Should be Empty: