Veterinary Notification Form

VETERINARY NOTIFICATION FORM

WHEREAS

WHEREAS, Veterinary Practice: , located at , provides medical, surgical and ancillary veterinary services to animals under its care;

WHEREAS, Client Name: is the owner or authorized agent of the patient identified below and seeks to establish notification, authorization, and billing procedures for services provided by Veterinary Practice; and

WHEREAS, the Parties wish to set forth notification preferences, the scope of authorized care, payment obligations, confidentiality protections, and governing law terms applicable to notifications and related administrative actions.

PATIENT INFORMATION

OWNER / CLIENT INFORMATION

NOTIFICATION PREFERENCES & AUTHORIZED CONTACTS

Preferred methods to receive notifications (select all that apply):

Phone call    SMS / Text message    Email    Postal mail

SCOPE OF WORK

Describe the diagnostics, treatments, procedures, or services for which the Client authorizes notification and, where applicable, authorization to proceed when the Client is unavailable:

PAYMENT TERMS

Estimated total cost (if known): $

Deposit required prior to procedure: Yes    No

If deposit required, deposit amount: $

Late payment terms: . Client agrees that overdue balances may incur collection costs and interest as stated above.

TERM AND TERMINATION

Effective Date: . This Notification Agreement shall remain in effect until End Date: , or until earlier terminated by either party in accordance with the notice provisions below.

Termination: Either party may terminate this Agreement by providing written notice to the other party at least prior to the intended termination date. Termination does not relieve Client of payment obligations for services rendered prior to termination.

CONFIDENTIALITY

All medical information and billing records pertaining to the patient are confidential and will be protected in accordance with applicable law. Veterinary Practice may disclose protected information to authorized contacts listed herein for the purpose of providing care and administering notifications. Client authorizes disclosure to the primary and alternate contacts designated in this form and may revoke that authorization in writing at any time, except to the extent that Veterinary Practice has relied on the authorization prior to revocation.

GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the State of without regard to its conflict of laws rules. Venue for any dispute arising under this Agreement shall lie in the courts of that state.

ENTIRE AGREEMENT

This Veterinary Notification Form constitutes the entire agreement between the Parties with respect to notification, authorization for routine administrative disclosures to the designated contacts, and associated payment arrangements, and supersedes all prior agreements and understandings, whether written or oral, relating to the same subject matter. Any amendment to this Agreement must be in writing and signed by both Parties.

ACKNOWLEDGMENTS & CONSENT

By signing below, Client authorizes Veterinary Practice to communicate with the contacts and by the methods indicated; acknowledges responsibility for payment for services rendered to the patient; and affirms that the information provided on this form is true and accurate. Client further acknowledges that certain clinical decisions may require explicit medical consent, and where such consent cannot be reasonably obtained, Veterinary Practice will follow the scope of work and authorization instructions herein when permitted by law.

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