Consent and Financial Responsibility Form

Thank you for choosing Heights & Hill Veterinary Hospital for your veterinary needs. We are committed to providing our clients and patients with the best possible treatment and service. The following is a statement of our financial policy which we request that you read, agree to, and sign prior to your appointment. A copy of this policy will be given to you if requested.

Name

First Name

Last Name

Pet(s) Name(s)

Financial Responsibility - Payment for Services Payment is due at the time of service. 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, and Care Credit.

Medical Fees, Estimates and Invoice 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.

Pet Insurance - 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 Heights & Hill Veterinary Hospital 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. Heights & Hill Veterinary Hospital is not responsible for knowing what your insurance policy will and will not cover.

Missed Appointments - 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.

Returns - You cannot return prescription or medicated products. Refunds may be issued for incorrect or damaged prescription or medicated products.

Interest and Service Fees - 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 30.00 will be applied to the outstanding balance at the time we create a monthly statement.

Collection - 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.

Financial Consent - I acknowledge that, by signing below, I am ultimately responsible for bills incurred when presenting the pet(s) of record to Heights & Hill Veterinary Hospital 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.

I certify that I have read, understand, and agree to this policy (initial below).*

Date