ContractService and Payment Agreement • November 22nd, 2016
We welcome you as our patient and look forward to providing you with the very best vision care and the highest quality materials available. Please review the following policies.
Service and Payment AgreementService and Payment Agreement • June 29th, 2022
Service and Payment Agreement 2023Service and Payment Agreement • June 28th, 2023
Client Name: Date of birth: Address: This is a (please circle) Permanent Residence/Interim Placement (please provide documentation if there are any court orders in place regarding placement). Parents/Carers: *Please provide documentation if there is a Family & Community Services Care arrangement in place. Contact email: Contact mobile: Name: Number:
ContractService and Payment Agreement • June 30th, 2014
We welcome you as our patient and look forward to providing you with the very best vision care and the highest quality materials available. Please review the following policies.
MOXEY SCHREIBER VETERINARY HOSPITAL, INCService and Payment Agreement • February 26th, 2021
Home Phone Number: Cell Phone Number: Email address: Place of Employment: Work Phone Number: Ext. # Spouse’s Place of Employment: Spouse’s Work Phone Number:
SERVICE AND PAYMENT AGREEMENTService and Payment Agreement • April 22nd, 2015
Authorization for Services: By virtue of my signature below, the undersigned hereby authorizes Beth Osten & Associates to provide such assessment and treatment services as may be deemed necessary and advisable for my child. The undersigned (individually referred to herein as “I”) reserve the right to refuse consent in the future to any proposed procedure or service.
MOXEY SCHREIBER VETERINARY HOSPITAL, INCService and Payment Agreement • June 26th, 2015
Payment in full is due upon completion of services. I/We understand that I/we am/are responsible for all invoiced charges. In the event payment is not received upon completion of services, a $2.50 or 3% whichever is greater, per month service charge will be added monthly until the account is paid in full. Any account balance in excess of $1000.00 will be charged a service charge at a rate of 1.75% per month.
Service and Payment AgreementService and Payment Agreement • May 15th, 2020
This agreement refers only to investment related business and does not include providing protection advice. We agree to provide you with services and in return you agree to pay us for our services, as detailed below.
