Hospital Authorization & Onboarding Form

Hospital Authorization & Onboarding Form

Please review, sign, and submit to confirm your agreement and commitment to the terms and payment obligations.
Hospital Name
Clinician Full Name

First NameLast Name
Medical Director / Hospital Administrator Name

First NameLast Name
Medical Director / Hospital Administrator Email
example@example.com
Authorization & Agreement to Proceed

By submitting this form, I confirm and agree that:
- I am a licensed veterinarian at the listed hospital.
- The information provided is true, accurate, and complete.
- I have the authority to bind the hospital.
- This submission is on behalf of the hospital to initiate onboarding with Atlantic ER Vet Consults, LLC.
- A Master Service Agreement (MSA) must be executed electronically before services are activated.
- The hospital will be bound by the MSA once executed.
- The hospital authorizes Atlantic ER Vet Consults, LLC to collect, store, and use a valid payment method (such as credit card or ACH) for billing according to the MSA.
- Submitting this form does not itself constitute the MSA or replace its terms.
- The hospital agrees to the financial commitments and promises to pay under the MSA.
I have read and agree to the above Authorization & Agreement to Proceed.
Signature
Date

MonthDayYear
Date
Should be Empty: