Consent to Veterinary Services Owner Name * First Name Last Name Owner Phone * (###) ### #### Mobile Phone * Yes No Owner Email Authorized agent This will allow another individual to make veterinary authorizations in the event that you are unable to reached. First Name Last Name Authorized Agent Phone (###) ### #### Mobile Phone Yes No Authorized Agent Email By signing below, I hereby: - Authorize Temecula Valley Veterinary to perform veterinary services on my animal(s) that I currently own, or will own in the future. - Authorize the above agent/trainer/caregiver to order veterinary services on my behalf. - Agree to pay the charges associated with the veterinary services and goods rendered to my animal(s). By signing below, I consent to the following: - Payment is due at the time of service. If the owner of animals will not be present at the appointment, a valid credit card must be kept on file to be charged upon completion of services. Monthly billing arrangements must be set up in advance and a valid credit card must be on file. - Accounts not paid in full within 60 days will be charged 3.5% interest per month on the balance due, and any additional services must be charged to a valid credit card or paid via cash or check at the time of service. - If an account is unpaid by more than 90 days or $500.00, Temecula Valley Veterinary reserves the right to decline further services and automatically charge the credit card on file. If legal action is necessary to collect unpaid invoices, attorney fees will be charged to the debtor. **All credit card payments will be charged a 3.5% transaction fee** Please charge the credit card on file for services rendered I would like to pay with an alternate payment method other than a credit card Signature * By typing your name below, you are signing this application electronically. Date * MM DD YYYY Credit Card Information Name on Card Credit Card Number Expiration Date 3-4 digit code Signature Date MM DD YYYY Click "Submit" to complete form. **All personal information is protected through digital encryption. No personal data is stored on the web.** Thank you!
