The above information is accurate and true to the best of my knowledge and I hereby authorize the veterinarian to to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal, and that these charges will be paid at the time of release. In the event of payment default will pay reasonable attorney's fees and costs of collection If payment becomes 20 days past due, service charges at an APR of 18% and a 5.00$/month billing *