Columbia Pike Animal Hospital - Financial Agreement Form

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FINANCIAL AGREMENT

Thank you for choosing Town & Country and Columbia Pike Animal Hospital (s) for your pet’s veterinary needs. It is our goal to provide exceptional and compassionate care. For this, a member of our team will communicate any test(s) and/or treatment before it begins.

Our hospital require payment at the time services are rendered.

Payment Options::

Cash, VISA, Mastercard, Discover, or American Express credit card.

CareCredit. A credit card specialized in health care costs with flexible payment plans of up to 12 months. Approval must be received prior to any treatment.

Scratchpay. A lending institution tailored to the veterinary industry. Pre-approval is needed before providing services.

Additional Payment Policy Information:

Checks are accepted in case-by-case situations. Returned checks are subject to $30.00 bank fee.

Unpaid balances of 30 days or greater will be subject to a 5% annual finance charge.

In the event your account is turned into collection for any past due balances of 90 days, a charge of 30% of the final bill will be applied.

Disclaimer
Credit card information will be automatically stored into our secured credit card vault system upon check out.
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****For safety concerns due to the current COVID-19 pandemic, our business will charge your credit card automatically upon checkout and email your invoice/receipt for your records.
* (initials)

In the event you wish to change your payment method, it is your responsibility to notify the front staff.

I * understand and accept all financial terms and conditions between Town & Country and Columbia Pike Animal Hospital (s) and me. I am aware that any unpaid balances and/or past due accounts will be subject to a 5% annual finance charge. I agree to pay for the costs of the collection charge of 30% of final bill, attorney fees, and court costs if collection efforts become necessary.
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Client Name* This field is required.
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Client signature* This field is required.
Clear
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Date* This field is required.
Date
Year
Month
Day
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Email* This field is required.
example@example.com
Should be Empty:

FINANCIAL AGREMENT