Payment Policy Form

Client Information
Pet Owner's Name (required):

Pet Owner's Phone Number (required):

Pet Owner's Email (recommended):

Pet Information
Pet Name (required):

Pet Gender (required):
—Please choose an option—MaleFemale

Pet Age (required):

Pet Breed (required):

Additional Pets (if applicable):
Pet Name:

Pet Gender:
—Please choose an option—MaleFemale

Pet Age:

Pet Breed:

The following is Aliante Animal Hospital’s standard policy regarding payment. Please read this carefully. If you have any questions, please see a receptionist for further clarification and any questions you might have:

• Payment in full is due at the time of service. Before services are provided, a deposit of 50% may be required at the discretion of the veterinarian.

• Acceptable forms of payment include cash, debit card, Mastercard, or Visa. Identification will be required for all non-cash payments. Personal checks are not accepted from newly established clients or clients who have been established for less than 3 months and have only had one paid visit.

• Aliante Animal Hospital does not do any “in-house” billing.

• In the event that charges should go unpaid for services rendered, the account will be turned over to an outside agency for collection. Should this occur the responsible party will be liable for all costs generated, including any additional collection fees (collection fees are generally 40% of the total amount owed) and/or reasonable court costs and attorney fees.

1. I am the owner or authorized agent for the owner and I am at least 18 years of age or older. I authorize Aliante Animal Hospital veterinarian(s) and healthcare team members to examine, prescribe for, or treat the pet(s) presented for care, and assume full financial responsibility for all charges generated by said care.

2. I give Aliante Animal Hospital permission to release my pet’s medical records to another animal care facility, should they be requested.

3. I understand that Aliante Animal Hospital may text me with updates about my pet for convenience. I also understand that text messaging is not an appropriate method for me to contact Aliante Animal Hospital for routine or emergency services. I understand that I must call Aliante Animal Hospital if my pet is in need and that text messages incoming to Aliante Animal Hospital will be neither replied to nor read.

4. Please indicate on your account with a receptionist any individual(s) [including your spouse or significant other] who has your consent to make changes to your account information, transfer your pet into a different owner’s name, and make medical and/or financial decisions on your behalf. All listed individuals must be 18 years of age or older.

Aliante Animal Hospital Photo Release Policy
The following is Aliante Animal Hospital’s standard policy regarding photos. Please read this carefully. If you have any questions, please see a receptionist for further clarification and any questions you might have.

Photo Release: I hereby grant Aliante Animal Hospital the right to photograph me and/or my pet(s) and the irrevocable right to use the photos in all types of advertising including but not limited to display on social media outlets, display on the internet, and display and/or broadcast on all other outlets known or unknown, for any purpose whatsoever.