By signing this document you are forming a contract with Auburn Equine/AMC Large Animal. This contract created certain rights and obligations including those described on the second page of this contract.
Patient Owner Information:
Date of Birth
Patient Information:
**PAYMENT IS REQUIRED AT THE TIME OF SERVICE**
Auburn Equine/AMC Large Animal does not bill insurance companies.
Terms and Conditions - Required:
Please initial after each statement
1. This contract shall apply to any and all services provided by Auburn Equine/AMC Large Animal to any and all horses/large animals on your behalf, whether or not the horse(s)/large animals are listed on the first page of this form.
Initial here:
2. I understand that I must pay all accounts in full at the time of service. If a credit card is provided, and you wish to have it charged at the time of service, we will agree to do so. Any time a charge is applied to your card, we will send you an invoice and receipt for your records. Credit card on file? Yes No (If yes, please fill out a credit card authorization form)
3. I Understand That If Payment Is Not Received In Full At The Time Of Service, Each Monthly Statement That Is Sent To Me Will Be Subject To A $15.00 Billing Fee.
I Understand That A Late Fee Of 1.5% Per Month Or 18% Annually Will Be Applied To All Accounts More Than 30 Days Past Due.
If, After 6 Months, No Payment Has Been Made, Past Due Accounts Will Be Sent To A Collection Agency.
Should Auburn Equine/Amc Large Animal Commence Administrative And/Or Legal Actions To Collect Unpaid Debt From Me:
A. I Consent To The Personal Jurisdiction Of The Courts Of The State Of California Over Me;
B. I Agree To Pay All Costs, Expenses And Reasonable Attorney's Fees Incurred By Auburn Equine That Are Associated With Such Action;
C. I Agree That Any Such Collection Action Shall Be Governed By The Laws Of The State Of California (As Applicable).
4. I hereby authorize Auburn Equine/AMC Large Animal to provide routine and emergency care to my horse (s) / large animals at my request or at the request of my agent (listed on front). I hereby authorize and direct the veterinarians of Auburn Equine/AMC Large Animal to perform the procedures, diagnostics and/or treatments that are agreed upon by myself or agent at the time of service. I understand that no guarantee has been made as to results or cure. I understand that there may be risks involved in some of these procedures.
5. I represent that I am presently able to comply with the payment terms set forth herein, and that if I should become unable to make timely payment of outstanding invoices, I will contact Auburn Equine/AMC Large Animal.
VETERINARY SERVICES WILL NOT BE PROVIDED WITHOUT YOUR SIGNATURE AND INITIALS INDICATING AGREEMENT WITH THESE TERMS.
Legal owner's name:
Owner's signature
Guardian's signature (if owner is under 18 years old)
Today's date:
By submitting this form, you agree to be contacted via the info given through email, phone call, or text message
