I hereby authorize VSCLI to perform medical and diagnostic/surgical procedures on my pet named above, as required for diagnosis and treatment. I understand that I can terminate treatment at any time by contacting the doctors and assistants. If I have been referred to this hospital by another veterinarian, he/she will receive a summary of the care and treatment provided by the VSCLI in order to ensure that my pet’s care can be continued without interruption. I also understand that VSCLI considers the identification of a referring veterinarian by me to be my authorization to release records and information to that veterinarian. In the event future ownership of this animal transfers to another party, I authorize release of medical information to the new owner, should they request it.
Payment is due as services are rendered. For hospitalized cases, a deposit is required in advance. The balance is due upon discharge from the hospital. You may pay by cash, personal check (with proper identification), or accepted credit cards. To avoid misunderstandings, please let us know immediately if there are any concerns regarding the terms of payment. In the event payment is not made at the time of service, it is our policy to apply a service charge to accounts with a balance over 30 days old. A service fee of $3.00, and 1.5 % of the outstanding balance will be charged to your account monthly if not paid in full. All returned checks will incur a charge of $35.00 and may be referred to the District of Attorney for collection. Names of Individuals responsible for the above pet and any Financial Obligations associated with said pet’s care for the above medical, diagnostic, or surgical care and/or treatment.
I understand that I (the owner or agent) am financially responsible to VSCLI for all charges relating to the above named patient. I have read and agree to the treatment authorization. I have also read and accept the financial obligations.
