Pet #1

Male Female
Yes No

Vaccination History (provide dates if known)

Pet #2

Male Female
Yes No

Vaccination History (provide dates if known)

Pet #3

Male Female
Yes No

Vaccination History (provide dates if known)

** Payment is Expected at the Time Services are Rendered **

We accept cash, in-state checks, Visa, MasterCard, and Care Credit.

By checking this field I here by authorize the doctors of Country Club Veterinary Clinic to administer such treatment as is necessary and to perform procedures therapeutically and/or diagnostically. I further understand that no guarantee of successful treatment is made. I also assume financial responsibility for all charges incurred, and agree to pay all such charges at the time of release. I understand that unpaid balances over 30 days are subject to a monthly 1.5% (18% APY) finance charge. Any balance that I leave unpaid will be forwarded to our collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges. There will be a $35 fee charged for any check that is returned. At your request we will gladly discuss cost of services and/or prepare a written estimate of recommended procedures/treatments. Deposits may be required for pets being admitted into the hospital.
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