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Chart # ___________________________
I hereby authorize the veterinary team at Hales Corners Veterinary Clinic to
examine, prescribe for, and treat my pet(s). I understand that payment is due at
the time of service, and I agree to pay for the services rendered at the time my
pet is checked out from the clinic. Payment is accepted via cash, check, or credit
card. CareCredit and ScratchPay are the only accepted third party payment plans.
I am aware that Hales Corners Veterinary Clinic does not hold checks or accept
postdated checks for any circumstance. In the event of default on payment or
noncompliance, I understand that I, the pet owner, am responsible for all billing fees, collection fees, and/or legal fees incurred by Hales Corners Veterinary Clinic
to collect the amount due.
If a client misses two (2) scheduled appointments or cancels two (2) appointments
on short notice, within one (1) years’ time, that client will be required to prepay
prior to scheduling future appointments. Short notice cancellation is constituted by
cancelling within 2 hours of the scheduled appointment time. If prepayment is
required at the time of scheduling, that prepayment will be applied to the invoice on
the scheduled appointment day. If that prepaid appointment is also missed or
cancelled short notice, the prepayment amount will be forfeited.
I give Hales Corners Veterinary Clinic permission to call my previous veterinary provider(s) to
retrieve medical records on my pet(s). I also give Hales Corners Veterinary Clinic permission
to release my pet’s vaccination records to boarding, grooming, or daycare providers, for
potential adoption of a new pet, and community licensing/health departments.
I hereby grant Hales Corners Veterinary Clinic permission to take photographs of my pet
and/or myself, and to publish those photographs for any lawful purpose, including, but
limited to, their website, social media accounts, and promotional materials, either digital or
in print, in perpetuity. I also grant permission to use my name and/or my pet’s name*
By signing and dating this document, I authorize Hales Corners Veterinary Clinic to edit and
share the photograph(s) mentioned above. I also waive any rights of privacy or
compensation associated with the use of my or my pet’s image(s) and name(s) for the
personal or commercial purposes outlined above.
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