Consent and Financial Responsibility Form

Permission is granted to the doctors, employees, and contractors of Center for Animal Health to do such procedures as requested and as may be necessary to diagnose, treat, and care for the needs of my pet(s) from this day forward. I hereby give my permission to release case and patient information with photos and/or video so they may be used in specialty consultation/referral, teaching/continuing ed., forms, websites, social media, broadcast, veterinary literature, and the like. (please initial)

Payment is due at the time of service. Patients admitted for diagnostics and/or treatment require a deposit toward procedures in the amount of 50% of the estimated or anticipated fees. We accept cash for payment. Personal checks are accepted if you have provided payment security information as requested. For your convenience, we accept Visa, MasterCard, Discover, American Express, Care Credit, and ScratchPay.

Estimates and updates on hospitalized patient bills are available upon request. Estimates provided by this office are a guideline only, and ultimately, invoices for services rendered, regardless of outcome, are the determinant of services due to be paid. Fees are subject to change without notice.

The balance for services is your responsibility, whether your insurance company pays or not. Your insurance benefit is a private contract between you and your insurance company and Center for Animal Health is not a party to that contract. We do not bill your insurance company. It is your responsibility to know the policies of your insurance company. Center for Animal Health is not responsible for knowing what your insurance policy will and will not cover.

No charge will be made for rescheduling an appointment provided 24 hour notice is given. Please remember that your appointment time has been reserved for you. Fees may be assessed for clients with repeated missed appointments.

There is a service charge of $25.00 on all checks returned for insufficient funds. Interest and service fees will apply as with any other outstanding balance.

In the event that a balance remains unpaid after service has been rendered, interest will accrue at a rate of 1.5% per month. and a billing service fee of 54.00 will be applied to the outstanding balance at the time we create a monthly statement.

Any outstanding balance left unpaid after reasonable attempts by this office to ensure payment shall be turned over to a collection agency without notice. Collection fees, interest, and attorney fees will be added to the balance due and those will become the responsibility of the client of record.

I acknowledge that, by signing below, I am ultimately responsible for bills incurred when presenting the pet(s) of record to Center for Animal Health for care, whether that guardianship has been assigned to others, or through implied assignment such as when my pet(s) are presented for care by a person other than me. I further agree to be fully responsible for the total payment of procedures performed by this practice, including any treatment that is not a benefit of any insurance.