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Registration Form

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Complete this form to authorize your pet’s treatment and acknowledge our payment and referral care policies.

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PET TREATMENT AUTHORIZATION

I am the owner of pets presented and authorize medical treatment of my pet(s) by the Orchard Park Veterinary Medical Center staff or assigns with my signature below.

Our recording software is utilized to support accurate record-keeping and to ensure quality control.

PAYMENT AGREEMENT

I agree to pay all fees associated with the care of my pet(s) which are subject to change based on the needs of my pet at the time of service. In the event that I fail to make payment in full for all services rendered by Orchard Park Veterinary Medical Center for the treatment of my pet(s) at the time of service, an interest charge of 1.5% per month shall accrue on unpaid account balances starting after 30 days.

Additionally, for all unpaid balances that become delinquent and that are turned over for third party collection, I agree to pay 40% collection and/or attorney fees, plus legal court costs for collection of debt. I further hereby authorize the exchange of medical records between Orchard Park Veterinary Medical Center and my veterinarian.

REFERRAL POLICY STATEMENT

You have been referred to the Orchard Park Veterinary Medical Center for consultation, diagnosis, medical treatment and/or a surgical procedure for your pet at the request of your veterinarian. We will work as a medical team with you and your veterinarian. Our staff will examine your pet, review diagnostic tests already performed and outline specific recommendations for further diagnostics or therapeutic intervention. If you choose to proceed with the recommended care plan, a written estimate of anticipated charges will be provided that will require your signature to acknowledge agreement and consent prior to beginning treatment.

At the conclusion of treatment for the condition for which your pet was referred to Orchard Park Veterinary Medical Center, a verbal and written report of treatment, procedure, and outcome will be forwarded to your veterinarian. If additional therapy is required for your pet’s condition that brought you to Orchard Park Veterinary Medical Center, it will be provided her or at your veterinarian’s hospital depending on the nature of the therapy needed.

We will NOT provide routine, preventative care for your pet(s), care for conditions unrelated to the one for which your pet was referred, or provide preventative care for any of your current or future pets. This includes new pets that you acquire or pets that you have that have never been referred to Orchard Park Veterinary Medical Center by your veterinarian for care. We ask that you contact you veterinarian concerning routine preventative care of your pets.

I have read and agree to comply with this policy.