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Client Information

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Patient (Pet) Information

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Signatures

Please read and agree to the terms, then sign and date below.

I am of legal age. I am the owner or authorized agent of the pet(s) presented to AVSG Internal Medicine & Emergency/Critical Care. I understand that an initial examination will be performed, and a verbal or written estimate will be provided to me before any other services are rendered. I assume financial responsibility for all professional fees and agree to pay at the time services are rendered. If for any reason payment is not made, I agree to interest charged per annum, necessary attorney’s fee, court costs, late fees, and any other recovery fees.

I understand that AVSG Internal Medicine & Emergency/Critical Care consists of leaders and teachers in veterinary medicine, thus case information and/or photos may be used in teaching, documentation, continuing education, their website, veterinary literature, and the like. I authorize the release of case/patient information for such purposes; patient confidentiality will be maintained unless otherwise authorized.

VSSOC and AVSG IMERCC seek to continually provide a welcoming and safe environment ensuring trust and respect for all people and pets. We have a zero tolerance for the use of threatening or aggressive behavior, abusive language, and threats of physical harm or violence. Words or actions that are disrespectful, racist, discriminatory, hostile, or harassing will not be tolerated. In the event that your behavior is problematic, we reserve the right to discontinue services immediately and you will be asked to leave the facility. I understand and abide by the code of conduct.

The cost for the Internal Medicine initial consultation is $266. The cost for the Emergency Care initial consultation is $194. I understand that the minimum cost of this appointment is $266 or $194 respective to the associated department and I agree to pay in full for this and any other services that I have agreed to at the time of the consultation.