New Client Form

By checking below, you certify that you are the owner/agent of the animal(s) listed above and that you also authorize the veterinarian to examine, prescribe, or treat the animal(s) above. You understand and agree that you will be held personally responsible for payment for all services provided by Countryside Veterinary Hospital. You further understand and agree that all sums shall be paid at time of service. If not received within 30-days of bill, a finance charge of 1.5% per month or $5.00 minimum, whichever is greater, shall be charged on the unpaid balance. If default of payment should occur, you agree to pay accrued finance charge, all costs of collection (including attorney fees) and other court costs incurred. For all new or un-established clients, a deposit of 75% estimated costs will be expected in the event of emergencies.

New Client Form

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Statement of Ownership

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