Surgery Deposit Agreement & Acknowledgment

Surgery Deposit Agreement & Acknowledgment

This form serves as a legally binding acknowledgment of the surgery deposit policy. Please read carefully before signing.
Client Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Pet & Appointment Information
Pet Name*
Date of Surgery*

MonthDayYear
Date
Type of surgery*
(Please list all, if more than one)
I acknowledge that a $200.00 surgery deposit and a signed Surgery Deposit Agreement are required to reserve my pet’s surgical appointment. I understand that both must be received by Monroe Veterinary Clinic within forty-eight (48) hours of scheduling in order to secure the appointment.

I understand and agree that this deposit will be applied toward the total cost of my pet’s surgical procedure if the surgery is completed as scheduled.

I further acknowledge and agree that the deposit is non-refundable if the surgery is not canceled at least forty-eight (48) hours prior to the scheduled surgery date and time.

I understand that failure to appear for the scheduled surgery or late cancellation (less than 48 hours’ notice) will result in forfeiture of the deposit, without exception.

* If your pet's surgical appointment is canceled or rescheduled before 48 hours, the deposit will be applied your account as a credit or may be transferred to a new surgical date.
I have read, understand, and agree to the Surgery Deposit Policy stated above.
Electronic Signature Consent

By signing below, I acknowledge that my electronic signature is the legal equivalent of a handwritten signature and that this agreement is binding and enforceable.
Client Electronic Signature*
Printed Name*
Date*

MonthDayYear
Date
Should be Empty:

Surgery Deposit Agreement & Acknowledgment

Client Information

Pet & Appointment Information

Electronic Signature Consent