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Locust Valley Deposit Consent Form

Locust Valley Veterinary Clinic
280 Forest Ave
Locust Valley, NY 11560-2150
United States
(516) 676-6161

Client Full Name:

Client Address:

Contact Phone #:

Patient Name:

Patient Species:

Patient Breed:

Patient Age:

Patient Sex:

Patient Weight:

Authorization

- This is strictly a deposit to HOLD the procedure date.
- This is NOT the low end of the estimate. This will go towards the low end of the
estimate.
- The remaining low end of the estimate will be taken the morning of drop off for
the procedure.
- This deposit will be applied to your final bill the day of the procedure.
- This is a non-refundable deposit, but it can be transferred to a different date if
rescheduled at least a week prior to the original scheduled procedure date.

Signature of Owner or Authorized Agent:

Signature

Date: