I, the undersigned owner or authorized agent of the above admitted patient(s), agree to assume responsibility for all charges incurred, and agree to pay all such charges at the time of service/release.

I hereby authorize the veterinarian to examine, prescribe for, or treat, the above-described pet(s). I assume responsibility for all charges incurred in the case of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment. If any amount becomes delinquent and it is necessary to refer the matter to a collection agency or an attorney or if a suit is filed, I agree to pay all collection costs, court costs, attorney fees, and interest/finance charges in addition to the amount owed.

ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.

Financial Policy

Thank you for choosing Louisville Family Animal Hospital. Our primary mission is to deliver the best and most comprehensive veterinary care available for your pet. An important part of the mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options. Louisville Family Animal Hospital requires payment in full at the end of your pet's examination and/or at the time of discharge.

Payment Options: We offer a variety of payment options including:

• Cash
• Check (exclusions apply for first time visits)
• Visa® , MasterCard® , American Express®, Discover®
• Monthly Payment Plans¹ from CareCredit®

Some treatments or healthcare plans requiring comprehensive care may require a 50% deposit to begin your pet's treatment.

Additional Policy Information:

Louisville Family Animal Hospital charges $35 for returned checks. A fee may be charged for clients who miss or cancel more than 3 appointments in a calendar year without providing the office 24 hours prior notice. For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier.

If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your pet.

By signing below you agree to the foregoing terms of payment.