Thank you for giving our hospital the opportunity to care for your pet. So that we may better able to meet your needs, please complete the following:
If you checked yes to this question please answer the following:
PAYMENT IS DUE WHEN SERVICES RENDERED. IF YOU HAVE ANY FINANCIAL CONCERNS WE WILL GLADLY PRINT UP AN ESTIMATE BEFORE SERVICES ARE RENDERED.
ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY: This information is accurate and true to the best of my knowledge. I understand that I am responsible to pay for services rendered, including reasonable attorney's fees and costs of collection in the event of default. I further understand that if payment becomes 30 dayspast due, delinquency Charge s at the lesser of the annual rate of 18%, or the maximum allowable rate, will be due on delinquent amounts from the date the payment was due.