Please fill out all required (*) information and click submit button at bottom of page. BY CLICKING THE “SUBMIT” BUTTON, YOU AGREE TO THE CONDITIONS BELOW:

CONSENT & AUTHORIZATION:  I hereby represent that I am over the age of 18 and authorize the veterinarian to examine, prescribe for or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid when the services are rendered and that a deposit will be required for treatment. Due to the nature of medical services, I understand that once a service is performed, the fee for that service is non-refundable.

SERVICE CHARGE:  In the case of non-payment, I hereby promise to pay an additional fee of 1.5% per month of the outstanding balance on the account together with any collection costs, plus 25% attorney fees. In the case of a returned check, I acknowledge that there will be a fee of $35 imposed by and payable to GSVS.