Veterinary Services Contract

Please note: By submitting this document, you are forming a contract with PIEDMONT EQUINE PRACTICE. This contract creates certain rights and obligations including, but not limited to, those described in this contract.

Payment is required at the time of service unless prior arrangements have been made. A credit card on file is required for all clients who wish to be billed monthly. Insurance claim payments for major medical claim will be sent to you directly from your insurance company.

Client Information
Name*
First Last
Spouse/Partner
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Employer*
Preferred method of contact?*
- Phone
- Text
- Email
Phone*
How did you hear about us?*
- Referral
- Website
- Facebook
- Ad
- Other
Please specify
Service Contract
- I understand that payment is expected for all services rendered at the time of my visit. We accept cash, American Express, Visa, Discover, MasterCard, Care Credit, and personal checks. If payment plans are needed for extensive medical or surgical treatment, a 50% deposit at time of treatment and an agreed upon repayment plan will be required.
- Should The Small Animal Clinic at Piedmont Equine be forced to commence administrative and/or legal action to collect unpaid invoices:
- Liability Disclosure Statement
- - The Small Animal Clinic at Piedmont Equine is open and staffed the following hours:
  - There will not be on-premise staff overnight on weeknights, federal holidays, or from 12:30 PM Saturday afternoon until 8:00 AM Monday morning.
  - Should your pet require intensive care monitoring during our closed hours, we recommend local 24-hour facility Artemis Veterinary Emergency & Specialty Services, who can be reached at (703) 722-9159.
  - I understand the level of care and supervision provided for my pet should he/she stay overnight at The Small Animal Clinic at Piedmont Equine.
  - Name*
    First Middle Last
  - Date*
    MM slash DD slash YYYY

Client Information

Service Contract

Liability Disclosure Statement