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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.
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