MOUNTAIN RIDGE ANIMAL HOSPITAL is dependent upon your payment of fees to maintain our high quality
of patient care. The hospital does not extend credit (Bill) and you are responsible for all fees for products and services rendered. We will be glad to provide an ESTIMATE FOR SERVICES at any time. A deposit will be required prior to initiating treatment.
AUTHORIZATION for EXAMINATION, TREATMENT, and ASSUMPTION OF FINANCIAL RESPONSIBILITY
I, the undersigned, authorize the veterinarian(s) and their staff at MRANH to examine the patient specifically described and identified above and to administer any medical, surgical, treatments and/or tests including sedation or anesthesia which is considered necessary based on findings during the course of examinations. I, assume responsibility for all charges incurred for services rendered to the patient. I understand there is a $25+ service charge for returned checks and that unpaid accounts accrue a $15 late fee after thirty (30) days, plus interest at the rate of 1.5% per month (18% per annum) compounded monthly. If collection action is necessary on this account, I agree to pay all costs of collection, plus attorney fees, whether or not a suit is filed. The parties agree to the exclusive venue and jurisdiction of the City of Lafayette, Colorado, for all matters arising from this agreement.
I have read this statement and
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