1. I authorize Alpine Animal Clinic to release my contact information and/or my pet’s vaccine information to the Humane Society, government officials, or to any individual that has found my pet and would like to return my pet to me. In addition, I authorize Alpine Animal Clinic to release my pet’s medical records to any veterinary facility that may request those records, for any reason.
2. I recognize that Alpine Animal Clinic requires payment in full for any and all services at the time those services are rendered. In addition, I recognize that Alpine Animal Clinic does NOT offer payment plans or in-house credit, but does accept Care Credit and Scratchpay.
3. I recognize that in order to pay by check, I must provide a valid Driver’s License # or State ID #. I also recognize that if my check is returned - for any reason - a $50 returned check fee will be added to the balance on my account, I will no longer be eligible to pay by check for future services, and if payment is not promptly made, my information may be provided to the Attorney General of Arizona for failure to pay.
4. I recognize that if my account maintains an outstanding balance for 30 days or more, a 3% service charge (or $3.00, whichever is greater) will be added to the balance of my account each month until paid in full, and my account may be suspended until paid in full. I also agree to pay for the reasonable cost of collection in the event that collection efforts become necessary - including a $35 fee for each certified letter that is sent to me and any fee assessed by the collection agency on behalf of my account.
5. I recognize that in the event my pet may require hospitalization, Alpine Animal Clinic does not offer or provide 24-hour supervision/care by either a technician or a veterinarian. If my pet requires emergency veterinary care or overnight supervision, the option of being referred to an appropriate facility will be made available to me.
6. I hereby authorize the veterinarian to examine, prescribe for, or treat the pets described on the previous page, and I assume responsibility for all charges incurred in the care of my pets.
7. I recognize that I may request an estimate for services at any time, and that all estimates expire 30 days after they are written. I also recognize that the final price for services may vary by as much as 25% from the estimate provided, and all prices are subject to change.
8. I recognize that if I decline services, for any reason, Alpine Animal Clinic may request that I sign an “Against Medical Advice” form before releasing my pet to my care.
9. I recognize that a $30 fee will be assessed for all walk-in appointments during business hours. I also recognize that a $20 fee will be assessed for any missed appointment, or if I am ten minutes or more late for my scheduled appointment. In addition, I recognize that if I am more than ten minutes late for my appointment, my appointment will be cancelled and I will be responsible for rescheduling my appointment.
10. I recognize that Alpine Animal Clinic will neither prescribe nor refill heartworm prevention without proof of a current negative heartworm test. Heartworm testing is required annually, or if more than one dose of prevention is missed.
11. I recognize that Alpine Animal Clinic REQUIRES RABIES VACCINATIONS for all feline and canine patients, unless proof of a documented medical condition can be provided or a Rabies Titer is authorized (at my expense). Only a veterinarian can waive this requirement. Anyone who refuses to adhere to this policy will be asked to seek veterinary care elsewhere.
12. I recognize that Alpine Animal Clinic is required by law to examine my pet prior to prescribing any medication or treatment. If the veterinarian authorizes refills of that prescription medication, those refills will no longer be available after the annual wellness exam expires. Annual wellness exams are only valid for twelve months. In addition, I recognize that “medical exams,” “surgical procedures,” and “technician appointments” do not qualify as an “annual wellness exam.”
13. I recognize that Alpine Animal Clinic is not obligated to notify me when a vaccination, examination, or diagnostic test is due. Reminders are available, as a courtesy, but it is my sole responsibility to keep up with these reminders and to notify Alpine Animal Clinic if my address/phone/email change. I will not hold Alpine Animal Clinic liable if I forget or neglect my pet’s routine vaccinations, examinations, or diagnostic testing.
14. Finally, I recognize that both Coconino County and Yavapai County require licenses and proof of Rabies vaccinations for any and all dogs living in Coconino or Yavapai County. It is my responsibility to pursue licensing, and Alpine Animal Clinic will not be held liable if my dog is found to be without a license or Rabies vaccination tag.
By signing below, I recognize that I have read and understand each of the statements outlined above.