Bush Advanced Veterinary Imaging

Contact Us

Phone: 571-209-1163
Fax: 703-775-0070
radiology@vetradassociates.com

We are available
Monday-Friday 9-5.

Holiday hours may vary, please call us for details.

Radiology
Radiology

Radiology Patient Registration

Client Information

Note: * indicates a required field

Patient Information

Pet Gender:

Spayed/Neutered:

Pet Type:

I authorize Veterinary Radiology Associates, its Veterinarians and designated support personnel to examine and provide treatment for the pet presented. I assume financial responsibility for all charges incurred to this patient. If I am not the owner of the animal I represent, I have been given authority by the owner to obtain medical and/or surgical treatment for this patient, and to incur charges for its care. I understand payment, in full, is due at the time at the time service is provided. I understand VRA does not bill. Third-party financing is available and information can be provided to me upon request. Any outstanding balance will incur a late charge of 1.5% per month. VRA will also recover reasonable collection costs, attorney’s fees and court costs incurred as a result of my failure to pay in accordance with this agreement. Any financial concerns should be discussed with the doctor prior to treatment in order to comprise a treatment plan in the best interest of the pet and pet’s family. Medical information and contact information may need to be shared with TLC services and other veterinary hospitals in an effort to have a collaborative treatment plan. I consent to the release of information pertaining to this patient.

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