VETERINARY SERVICE CONTRACT

    By signing this document you are forming a contract with Auburn Equine/AMC Large Animal. This contract created certain rights and obligations including those described on the second page of this contract.

    Patient Owner Information:

    Date of Birth

    Patient Information:

    **PAYMENT IS REQUIRED AT THE TIME OF SERVICE**

    Auburn Equine/AMC Large Animal does not bill insurance companies.

    Terms and Conditions - Required:

    Please initial after each statement

    1. This contract shall apply to any and all services provided by Auburn Equine/AMC Large Animal to any and all horses/large animals on your behalf, whether or not the horse(s)/large animals are listed on the first page of this form.

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    2. I understand that I must pay all accounts in full at the time of service. If a credit card is provided, and you wish to have it charged at the time of service, we will agree to do so. Any time a charge is applied to your card, we will send you an invoice and receipt for your records. Credit card on file? Yes No (If yes, please fill out a credit card authorization form)

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    3. I Understand That If Payment Is Not Received In Full At The Time Of Service, Each Monthly Statement That Is Sent To Me Will Be Subject To A $15.00 Billing Fee.

    I Understand That A Late Fee Of 1.5% Per Month Or 18% Annually Will Be Applied To All Accounts More Than 30 Days Past Due.

    If, After 6 Months, No Payment Has Been Made, Past Due Accounts Will Be Sent To A Collection Agency.

    Should Auburn Equine/Amc Large Animal Commence Administrative And/Or Legal Actions To Collect Unpaid Debt From Me:

    A. I Consent To The Personal Jurisdiction Of The Courts Of The State Of California Over Me;

    B. I Agree To Pay All Costs, Expenses And Reasonable Attorney's Fees Incurred By Auburn Equine That Are Associated With Such Action;

    C. I Agree That Any Such Collection Action Shall Be Governed By The Laws Of The State Of California (As Applicable).

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    4. I hereby authorize Auburn Equine/AMC Large Animal to provide routine and emergency care to my horse (s) / large animals at my request or at the request of my agent (listed on front). I hereby authorize and direct the veterinarians of Auburn Equine/AMC Large Animal to perform the procedures, diagnostics and/or treatments that are agreed upon by myself or agent at the time of service. I understand that no guarantee has been made as to results or cure. I understand that there may be risks involved in some of these procedures.

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    5. I represent that I am presently able to comply with the payment terms set forth herein, and that if I should become unable to make timely payment of outstanding invoices, I will contact Auburn Equine/AMC Large Animal.

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    VETERINARY SERVICES WILL NOT BE PROVIDED WITHOUT YOUR SIGNATURE AND INITIALS INDICATING AGREEMENT WITH THESE TERMS.

    Legal owner's name:

    Owner's signature


    Guardian's signature (if owner is under 18 years old)


    Today's date: