REGISTRATION FOR ACCOUNT


CREDIT POLICY

Invoices are prepared on the first of each month for the previous month’s requisitions. Requisitions submitted at the end of the month may appear on the next month’s invoice. Invoices are delivered via email to up to two email addresses. A valid form of payment must be on file before any requisitions will be processed. Payment may be made by either credit card or direct bank withdrawal. All payments are automatically processed on the first of each month.

 I have read and understand the PETLABS DIAGNOSTIC LABORATORIES INC. Credit Policy.

RECURRING PAYMENT AUTHORIZATION

I authorize PETLABS DIAGNOSTIC LABORATORIES INC. to initiate either an electronic debit against my bank account or to charge my credit card according to the terms of the Credit Policy.

I acknowledge that any originating ACH transactions to this account must comply with the provisioning of United States law.

Hospital Name:
Billing Contact Name:
Billing Contact Phone:
Invoice Email Address:
Second Invoice Email Address (optional):
I prefer to pay via:  Bank Draft from my checking account      Credit Card
A billing representative from PETLABS DIAGNOSTIC LABORATORIES INC. will contact you to obtain valid payment information.


This payment authorization will remain in full force and effect until I notify PETLABS DIAGNOSTIC LABORATORIES INC. of its cancellation by sending written notice in such time and such manner that allow both PETLABS DIAGNOSTIC LABORATORIES INC. and the receiving financial institution a reasonable opportunity to act upon it.

Electronic Signature:
Date:


Registration to access records. Password to be between 6-20 characters


Hospital Name:
Address:
City:
State:
Zip:
Phone:
Fax:
First Name:
Last Name:
Email:
Confirm Email:
Password: