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Payment Plan Agreement

Agreement to pay a veterinary balance in installments

Client

Client / owner namePhoneAlternate phoneAddressEmail

PatientInvoice #Date of serviceServices covered

Balance & terms

Total balance$Down payment today$Amount remaining$Number of paymentsPayment amount$FrequencyFirst payment dueFinal payment duePlan fee (if any)$Interest (if any)%Late fee (if any)$Grace perioddays

Payment method

Card on file, charged automaticallyCard, I will call inCash / check at the clinicOnline payment link

Schedule & payment record

#	Due date	Amount due	Date paid	Amount paid	Balance left	Staff
1
2
3
4
5
6
7
8
9
10

Terms

If a payment is missed (practice to complete)

I agree to pay the balance above according to this schedule. I understand that future non-emergency services may require payment at the time of service while a balance is outstanding, and that I may pay the balance in full at any time.

Client signature

Printed nameDate

Practice representative signature

Printed nameDate

+Add logo

Payment Plan Agreement

Agreement to pay a veterinary balance in installments

Client

Client / owner namePhoneAlternate phoneAddressEmail

PatientInvoice #Date of serviceServices covered

Balance & terms

Total balance$Down payment today$Amount remaining$Number of paymentsPayment amount$FrequencyFirst payment dueFinal payment duePlan fee (if any)$Interest (if any)%Late fee (if any)$Grace perioddays

Payment method

Card on file, charged automaticallyCard, I will call inCash / check at the clinicOnline payment link

Schedule & payment record

#	Due date	Amount due	Date paid	Amount paid	Balance left	Staff
1
2
3
4
5
6
7
8
9
10

Terms

If a payment is missed (practice to complete)

Client signature

Printed nameDate

Practice representative signature

Printed nameDate