Volume Client Payment Update

Primary Contact Information

Volume Client Organization

Date

Main Contact- First name

Main Contact- Last name

Organization street address, city, state & zip code

Main Contact- Phone

Main Contact- Email

If an animal presents for surgery and additional minor medical conditions are found needing attention such as ear or skin infections or masses etc. that should have a cytology do you consent to treatments automatically:

Up to $50

Up to $100

Always contact us first for each patient if over $100

Any amount, I give full consent

No additional amount approved until verified by rescue or shelter

No additional services

Payment Preferences

I understand that services must be paid for as they are rendered and will pay after each invoice is sent. Payment can be made by debit/credit card or check. A 3% surcharge fee may be added to all credit card transactions.

Our organization will provide payment by check after invoicing.

Keep our credit card on file. I authorize WCVC to process payments as services are rendered.

I would like to set up portal access and pay by credit card through my portals.

Card Number

Expiration

CSC code

Name on Card

I understand that invoices not paid as agreed will result in suspended services and possibly collections . I understand that WCVC has the right to withhold all ongoing services, lab results, and records until any dispute is resolved.

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I understand that an administrative fee may be charged for any/each appointment reserved but not used if at least 3 days notice was not given.

Modo de dibujo seleccionado. Para dibujar, necesitas un mouse o un panel táctil. Usa la función de accesibilidad del teclado al seleccionar Escribir o Subir.