The NYS Professional Board of Ethics requires a written and signed release in order to provide any medical information. This information can be revoked at any time. I authorize Hopewell AH to release medical records for my pet to the following (check all that apply):

Payment in full is expected at time of service. Returned checks will receive a non-sufficient funds fee of $30 placed onto the account. Interest will be charged once monthly on any balance placed on account. The account will be sent to collections if no payment is received within 90 days. The account may accrue a $30 collections charge. We appreciate your cooperation.