Consent Form

Legal Consent and Payment Terms
• Payment is required at the time of service unless other arrangements have been made prior to the appointment.

• If the horse is insured, payment will be made directly to Dr. Amy Polkes for the services performed and reimbursement will come from your insurance company.

• I understand that I must pay my account in full within 30 days of the invoice. Invoicing is done through email and an accurate email address will be provided.

• Late charges shall be applied to all overdue accounts at the rate of 1.5% monthly.

• The credit card on file will automatically be charged unless a check is provided the day of the visit, or alternate payment arrangements are made. Any time a charge is applied to your card, a paid invoice will be provided for your records.

• Should Hudson Valley Equine Internal Medicine have be required to commence administrative or legal action to collect an unpaid balance from you:
o You agree to pay all costs, including reasonable attorney’s fees, incurred by Hudson Valley Equine Internal Medicine associated with such action.
o You represent that you are presently able to comply with the payment terms herein. If you should become unable to make timely payment of an outstanding balance, you will contact Hudson Valley Equine Internal Medicine.

• I hereby authorize Hudson Valley Equine Internal Medicine to provide care to my horse(s) in my absence or at the request of my authorized agent.
• This contract shall apply to any and all veterinary services provided by Hudson Valley Equine Internal Medicine to any and all horses on my behalf.

By submitting this form, you acknowledge that you understand and accept these terms.

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