Deposit Form

Name: RoxPaw Animal Clinic
Address: 8361 N. Rampart Range Road B103, Littleton, CO, 80125, United States
Telephone: 303-973-8070
Price range: $

APPOINTMENT

Please complete this form.

Owner's Information

Name *

First

Last

Email *

Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient Name: *

Agreement

I, The owner of the appointed caregiver of the pet named above have the authority to execute this consent. *

I Agree

I hereby authorize RoxPaw Animal Clinic to collect the deposit in the amount of: (Select option below) *

Radiology: $200
Cardiologist: $200
Surgery: $250

I understand that by signing this form, I agree to the following:

The deposit collected is to secure and schedule a surgical/specialist appointment for my pet. *

The deposit collected will go towards the balance of the procedure/specialist visit. Should I need to cancel or reschedule, RoxPaw Animal Clinic requires a 72 hour notice. The deposit is fully refundable as long as the 72 hour notice has been provided. If less than 72 hours is provided, the entire deposit will be forfeited and not refunded. *

I understand and agree to pay the balance in full at check-out on the day of my pet's surgical/specialist appointment. *

I understand that by signing this form, I agree that the deposit collection, procedure, and relevant cost have been fully explained to me. *

I have read, understand, and agree to the terms and conditions herein. *

First

Last

Date *

Phone