Date Format: MM slash DD slash YYYY
(Driver’s license required if paying with a check)
- • The phone numbers that you list will be considered primary contact numbers.
• Please check the box by your preferred contact phone number.
• If you use your cell as your home number, please list it as both the cell and home numbers.
(ex. spouse cell)
Thank you for choosing Lewisburg Animal Hospital. Our primary mission is to deliver the best and most compassionate veterinarian care available to your pet. Furthermore, we are committed in making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options. Lewisburg Animal Hospital requires payment in full at the end of your pet’s visit and/or at time of discharge. We only ask that you understand your responsibility and for the payment of your account balance.
Our basic financial policy is the following:
FULL PAYMENT IS DUE AT THE TIME OF SERVICE
• WE ACCEPT CASH, CHECK, MONEY ORDER, VISA/MASTERCARD, AMERICAN EXPRESS or DISCOVER
• WE ACCEPT CARE CREDIT
• IF YOU HAVE PET INSURANCE, WE ARE HAPPY TO PROVIDE YOU WITH THE NECESSARY DOCUMENTATION TO SUBMIT A CLAIM TO YOUR INSURANCE COMPANY. BUT IN NO WAY ARE RESPONSIBLE FOR YOUR AGREEMENT WITH THE INSURANCE PROVIDER.
For some treatments or hospitalized care, a deposit may be required. Healthcare plans requiring comprehensive care of more than $400.00 will require a 50% deposit to begin your pet’s treatment.
All customers are responsible for full payment at the time of service unless specific arrangements are made prior to the start of your pet’s treatment.
Client Responsibilities and Additional Terms
Accounts unpaid 30 days after receiving the first statement are subject to a delinquent fee of $25.00. Furthermore, the unpaid balance is subject to a 1.5 % monthly (18% Annual) finance charge with a $4.00 minimum. If we have to submit your unpaid account to a collections process you will be responsible for all charges our practice incurs; including late fees, finance fees, collection cost, staff costs, court filing fees and reasonable attorney’s fees. Any returned checks or credit card payments will carry a $35.00 service charge.
I have read, understand and agree to the terms of Lewisburg Animal Hospital’s financial policy.
A picture ID is required with your signature.