OWNERSHIP: I certify that I am the legal owner of the animal(s) listed on this account and consent to medical treatment of the presented animal(s).
AUTHORIZATION FOR TREATMENT: I hereby authorize and accept financial responsibility for Purdue University Veterinary Hospital (PUVH) to examine my animal(s) by the attending professionals, which includes all veterinarians, vet technicians, vet assistants, and clinical students. I further authorize and accept financial responsibility for the services, procedures, diagnostics, vaccinations, treatments, and/or administered medications explained to me by PUVH attending professionals.
EMERGENCY SERVICES: I authorize and accept financial responsibility for services, procedures, diagnostics, vaccinations, treatments, and/or administered medications performed by PUVH attending professionals that arise during an emergency and understand I may not be consulted until my animal is stabilized.
ISOLATION SERVICES: I authorize and accept financial responsibility for the services, procedures, diagnostics, vaccinations, treatments, and/or administrating medications performed by PUVH attending professionals that arise from a suspected or confirmed infectious disease.
USE OF MEDICAL INFORMATION / IMAGES FOR TEACHING & RESEARCH: The PUVH is an academic medical center that uses clinical services for educational and research purposes. I acknowledge and agree that the PUVH, its agents, and assigns may have full and free use of photographs, medical record data, and/or video taken of me and my animal(s) for teaching and research purposes as a requirement to receive services.
EMERGENCY VISITS: I acknowledge that if visiting the Emergency Department with my animal, the total cost of an exam will be required at check-in. If an animal(s) present to the hospital in an unstable condition, I acknowledge that a higher deposit may be needed.
COMPLICATIONS: I acknowledge that there is no guarantee as to the results of any procedures, diagnostics, treatments, administered medications (including vaccinations), and/or surgeries. I understand that there is always a risk of known or unknown complications with any procedures, diagnostics, treatments, administered medications (including vaccinations), and/or surgeries my animal receives while under the care of the PUVH, including the possibility of infection, injury, or death.
HOSPITAL ADMISSION / DEPOSITS: I acknowledge that if my animal is admitted to the PUVH, an initial estimate range will be provided, and a deposit equal to the lower estimate or 50% of the higher estimate, whichever is greater, will be required before receiving further treatment. I understand that as the treatment for my animal progresses, the estimate may increase and require additional deposits to continue treatment. Any remaining posted outstanding balance will be due at the time of the animal's discharge from PUVH.
MEDICAL & FINANCIAL UPDATES: The PUVH will provide periodic medical updates for patients admitted to the hospital. At least one update every 24 hours will be provided to owners via the primary phone number on file for stable patients. We will attempt to provide more frequent updates for unstable patients. If you miss our call and your animal is stable, we will provide your update via voice message and/or electronically. If an animal is unstable, we will request that you return our call, and we will make every attempt to connect with you to provide the update once you call back. Financial updates will be provided upon your request or if your current balance is approaching the high-end estimate, requiring a new estimate and/or additional deposit.
I acknowledge that in the event PUVH is unable to reach me over a 24-hour period, PUVH will continue to provide the most appropriate care plan for my animal, and I am still responsible for any charges incurred for the care of my animal even if I have not provided specific authorization for such care.
ANIMAL ABANDONMENT: The PUVH fully complies with the State of Indiana law regarding abandoned animals and euthanasia (IC 25-38.1-4-8)
ELECTRONIC SIGNATURES: As the legal owner, I acknowledge that when/if I sign documents electronically, those signatures are the legal equivalent of my manual/handwritten signature and are treated the same as if I signed the document in person. I understand that if I do not wish to sign documents electronically, I can request to complete forms by hand in person. Furthermore, I acknowledge I can request a copy of any signed documents, electronically or otherwise, at any time.
CURRENT & FUTURE VISITS: I understand this agreement covers my entire account and all animals listed therein. This agreement is automatically renewed each subsequent visit that I bring my animals to the PUVH unless a new agreement is executed. Furthermore, I understand I can request a copy of this agreement at any time or locate the policy on the hospital’s webpage.
Financial Agreement
FINANCIAL RESPONSIBILITY:
OWNER: I acknowledge that I am financially responsible and agree to pay for all charges incurred relating to my animal’s care. I further acknowledge and agree that it is my responsibility to understand the costs associated with my animal’s care and maintain knowledge of my financial obligations to the Purdue University Veterinary Hospital (PUVH).
CO-OWNER / AGENT FOR OWNER (AFO): I certify I am financially responsible for all costs associated with my animal’s care that were authorized by those to whom I have granted permission via the Client Demographic Form on file.
PAYMENT: When an animal is discharged from the PUVH, the posted outstanding balance is due in full for all inpatient and outpatient services.
METHODS OF PAYMENT: PUVH accepts cash, checks, credit/debit cards, and CareCredit for payments. If payment is by check that cannot be processed due to insufficient funds (NSF), a $25 return check fee will be added to your account.
CARE CREDIT: The PUVH partners with CareCredit, a third-party company, to provide alternative payment arrangements. CareCredit offers longer payment terms and low to no interest, depending on balances. This line of credit option requires an application through CareCredit's website and is subject to approval directly from CareCredit.
CREDIT/DEBIT CARD PAYMENTS: I acknowledge that the PUVH will tokenize my credit/debit card information when making a payment. This means the actual payment card data will be replaced with a token and securely stored “on file” in the PUVH billing system, accessible only to authorized members of our billing staff. This stored token will be used for recurring payments, future payments, collection of unposted fees, and/or refunds as appropriate. I understand PUVH will charge my stored tokenized card for all charges associated with my visits, including those that may be posted to my account after my animal(s) are discharged.
CLIENT BILLING:
UPAID BALANCES: I acknowledge that the PUVH will attempt to collect, via my tokenized card, any charges that were not collected for whatever reason at the time my animal was released and discharged from the hospital, including unposted fees.
UNPOSTED FEES: Unposted fees refer to services and subsequent charges rendered in the hospital that were still in the processing stage when the animal was released and discharged from the hospital. I acknowledge that the PUVH has 30 days from the date of discharge to post all final charges to my account, and I agree to pay for these services and subsequent charges. PUVH will charge my tokenized card to collect these charges.
INVOICING: Clients will be notified by the PUVH within 30 days of finalized balances via postal mail, phone call, and, if consented to, emails and/or text messages. The PUVH will invoice accounts with balances once per month, and I acknowledge that I have 30 days from the first invoice date to pay in full to avoid service disruptions and/or late fees. Furthermore, I agree that if a balance remains unpaid after 30 days from the first invoice date, a late fee of $25 or 25%, whichever is lower, will be added to the account.
REFUNDS:
Accounts with a credit balance will be refunded using the original form of payment. Care Credit will be refunded first if multiple payment sources are used unless I explicitly request otherwise.
Cash and check payments can only be refunded by check and will be mailed to the address on file.
I understand any unclaimed credit(s) will be submitted to Indiana Unclaimed after 180 days.
AFTER-HOURS PICK-UP / DROP-OFF (Brunner Equine and Farm Animal Hospitals): Pick-ups and drop-offs occurring outside of normal business hours and on weekends require prior approval and are subject to additional fees including additional hospital fees. Any non-emergency after-hours pick-up or drop-off without prior arrangement may be denied entry to the hospital until the next business day.
COLLECTION COSTS: As owner/agent, I understand that multiple attempts via postal mail, phone, email, and/or text will be used to notify me of any balances owed. If an account remains unpaid, the account will be turned over to Purdue’s Account Resolution Team (ART). Once this occurs, I understand the PUVH will rescind any previously posted discounts applied to the unpaid visit, my account will be locked and future services at the hospital or on my farm will not be allowed for my animals until all outstanding balance(s) are paid in full.
ACCOUNTS RECEIVABLE: ART will also attempt to collect outstanding balances and associated fees mentioned in this section. If unsuccessful, I acknowledge that my account may be sent to an outside collection agency and/or pursued in Small Claims Court. If this occurs, I understand that delinquency data about me may be sent to the three credit reporting bureaus. I am responsible for any fees associated with attempting to collect the outstanding balances, and I will not be accepted at PUVH for future care of my animal(s).
