Payment Policy Form

Please fill out the new patient form.

First Name

Last Name

Email Address

Phone Number

Employer Name & Address

Who may we contact, other than yourself, in case of an emergency with your pet?

Emergency First Name

Emergency Last Name

Emergency Phone Number

Please list any persons other than yourself who have permission to consent to medical treatment for your animals:

All services MUST be paid for in full at the time of service, with NO EXCEPTIONS. This shall include routine health examinations, vaccinations, routine laboratory tests, surgeries, emergencies, perscription and non-prescription medicines, food and supplies. Payment may be made with Cash, Visa, MC, Discover, American Express and Care Credit. If payments are not received and the account becomes delinquent, the account will be subject to collections and/or legal action to enforce collection of money owed. If this becomes necessary, all expenses incurred in the collection of the debt including court costs and attorney's fee shall become the responsibility of the debtor in default. A service charge of $35.00 will apply in addition to the above, for any uncollected or returned checks.

I have read the payment policy above, I agree to the terms and will follow the guidelines of the agreement and acknowledge that I am fully responsible for the charges incurred in the treatment of my animal.

Yes

I grant to Badger Veterinary Hospital, its representatives and employees, the right to take photographs of me /and or my pets, and to copyright, use , and publish the same in print and/or electronically. I agree that Badger Veterinary Hospital may use such photographs of me and/or my pets with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content.

Yes

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Payment Policy Form

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Payment Policy Form

New Patients Welcome