Treatment Authorization and Information/Photo Release
I hereby authorize ACIC to perform medical and initial diagnostice/surgical procedures on this animal as required for diagnosis and treatment. I understand that I can terminate treatment at any time by contacting the doctors and assistants.
If you were referred to our clinic by another hospital or veternarian, they will require a summary of your pet's care and treatment in order for your pet's care to continue without interruptions. ACIC considers that your identication of a referring veterinarian implies your authorization to release records and information to that referring veterinarian.
Information and/or photos may be used in teaching, forms, continuing education, web site, veterinary literature and the like. I authorize the release of case/patient information for such purposes; patient condentially (names withheld) will be maintained.
Financial Policy
Payment is due as services are rendered. You may pay by cash, personal check, and accepted credit cards. In order to avoid misunderstandings, please let us know immediately if these terms are not satisfactory. There is a $25.00 returned check fee.
Authorization
I am the owner of the above pet, or am acting as the agent for the owner, and accept full financial
responsibility.