Veterinary Contract

Client Information
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Spouse / Partner
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Address
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Home Phone
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Service Contract
I understand that payment is expected for all services rendered at the time of my visit. We accept cash, American Express, Visa, Discover, MasterCard, Care Credit, and personal checks. If payment plans are needed for extensive medical or surgical treatment, a 50% deposit at time of treatment and an agreed upon repayment plan will be required.
Should The Small Animal Clinic at Piedmont Equine be forced to commence administrative and/or legal action to collect unpaid invoices:*
- I consent to personal jurisdiction of The Circuit Court of Fauquier County
*
- I agree to pay all costs and attorney's fees incurred by The Small Animal Clinic at Piedmont Equine that are associated with such action.
Authorization
I have read and understand the above service contract. By signing below, I verify that all the information provided above is accurate to the best of my knowledge.
Signature
Date
Date Format: MM slash DD slash YYYY

Client Information