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4340 North Roan Street
Johnson City, TN 37615

423-282-6194

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Veterinary Service Agreement

The veterinarians and staff at Mountain Empire Large Animal Hospital are committed to provide our patients and clients with quality and compassionate care. By signing this document, you are initiating a client/ veterinarian relationship with Mountain Empire Large Animal Hospital. This relationship creates certain rights and obligations including, but not limited to, those described on the second page of this contract. This agreement applies to all animals owned or leased by client and applies to any veterinary services, including but not limited to, in or out patient services, medications, supplies, and farm calls to any animals on clients behalf.

"*" indicates required fields

Name*
Spouse Name
Address*

Patient Information

Sex*

Financial Policy Agreement

I must pay at the time of service or have my credit card on file billed when services are provided. (Your credit card will be kept on file in an electronically secure system)*
I agree to provide Mountain Empire Large Animal Hospital with current information regarding changes of address, phone numbers, credit cards, or expiration dates.*
All hospitalized or surgical cases will require a deposit upon arrival and must be paid in full prior to discharge.*
All medications or supplies purchased at the hospital will be required to be paid at time of purchase.*
Late charges shall be applied at a rate of 1.5% per month.*
Late charges shall be applied at a rate of 1.5% per month.*

Should Mountain Empire Large Animal Hospital be forced to pursue legal action to collect unpaid invoices from me:

I consent to personal jurisdiction of the State of Tennessee*
I agree to pay all costs, expenses, and reasonable attorney fees.*
MM slash DD slash YYYY

Veterinary Services will NOT be provided without signature and complete information.

This field is for validation purposes and should be left unchanged.
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