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Terms of Service

CLIENT CONSENT FOR SERVICES, TERMS OF SERVICE, AND PAYMENT POLICIES

 

THIS AGREEMENT DESCRIBES HOW TO PROVIDE CONSENT FOR VETERINARY TREATMENT FOR YOUR PET(S) AND TERMS/POLICIES OF KAREN SUEDA VETERINARY BEHAVIOR INC.

 

PLEASE REVIEW IT CAREFULLY BEFORE AUTHORIZING

You may request a printed copy of this Agreement by emailing info@ksvetbehavior.com

I. WHO WE ARE This Notice describes the Terms of Service of Karen Sueda Veterinary Behavior, Inc. (KSVB), including: •All veterinary healthcare professionals including but not limited to veterinarians, technicians, staff, volunteers, contractors, and sub-contractors employed by or associated with KSVB. The term “I”, “me” or “my” indicates/refers to the client or client’s authorized representative.

II. CONSENT FOR TREATMENT By initialing and checking the box below, I hereby consent to and authorize the performance of all diagnostic tests, treatments and other veterinary medical services by KSVB for which they deem advisable. I understand that “veterinary medical services” encompasses both physical and behavioral medicine and may include, but are not limited to behavior observations, assessment tests, physical examination, training, behavior modification and veterinarian-client communication. By scheduling an appointment for my pet(s) with KSVB, I am agreeing to consent for treatment of my pet(s) by KSVB.

III. TERMS AND CONDITIONS OF SERVICE (VCPR; TELEHEALTH; LIABILITY; NO GUARANTEE; PRIVACY; COMMUNICATION; CANCELATIONS; LATE ARRIVALS; RESPECTFUL CONDUCT) By initialing and checking the box below, I hereby agree to be bound by the Terms and Conditions of Service outlined below. A.Veterinary-Client-Patient Relationship (VCPR). I understand that a VCPR is only established once the following conditions, outlined in Section 4826.6 of the California Business and Professions Code, have been met: a.“The client has authorized the veterinarian to assume responsibility for medical judgements regarding the health of the animal patient.” b.“The veterinarian possesses sufficient knowledge of the animal patient to initiate at least a general or preliminary diagnosis of the animal patient’s medical condition.” c.“The veterinarian has assumed responsibility for making medical judgements regarding the health of the animal patient and has communicated with the client a medical, treatment, diagnostic, or therapeutic plan appropriate to the circumstances.” By scheduling an appointment with KSVB, I and/or my representative(s) authorize KSVB to assume responsibility for medical judgements regarding the health of my pet(s). I may voluntarily end the VCPR at any time and for any reason. Disclosure of the cause is not required but is appreciated so KSVB can better serve other clients and patients in the future. In rare situations in which KSVB elects to end the VCPR, KSVB will provide referral information to other behaviorists and/or veterinarians. B.Telehealth/Telemedicine. Telehealth appointments conducted via synchronous audio-visual communication have limitations compared to an in-person visit and are not recommended for every patient. I acknowledge that KSVB evaluates the appropriateness of telehealth appointments on a case-by-case basis and that my pet may or may not be a suitable candidate. (For more information, refer to the documents discussing Telehealth/Telemedicine available by emailing info@ksvetbehavior.com.) C.Liability. As the representing owner, agent or handler who will be working with the pet(s) indicated below, I understand that behavior therapies recommended by KSVB may involve some level of risk to the pet(s) and/or the handlers, other people, other animals, and/or property despite best efforts to minimize them. I will use my own judgment and common sense when following the recommendations to not place people, pets/animals and property at undue risk. Furthermore, I realize that Dr. Karen Sueda, KSVB and its agents cannot guarantee that a pet will not be aggressive or cause injury to people, animals or property in the future and that the pet’s owner(s) and handler(s) continue to assume all liability for any future aggression. By initialing and checking the box below, I am freely assuming these risks and do not hold Dr. Karen Sueda, KSVB, its clinicians, technicians, agents, employees, or owners/agents for any facility used to see cases liable for any injury which may occur to handlers, pet, other people, other animals, or property while using their training and medication treatment recommendations. D.No Guarantee. Hiring of a veterinarian/veterinary behaviorist is an important decision. I understand that each pet’s outcome depends on a variety of factors and no veterinarian can guarantee a positive result in any particular case. Although KSVB endeavors to provide, to the best of their ability, an accurate diagnosis, honest prognosis, tailored treatment plan and supportive care based on knowledge, experience and the information provided, KSVB cannot guarantee, warranty or predict short- or long-term outcomes and that results experienced by other clients and patients do not guarantee a similar outcome. E.Veterinary Recordkeeping and Privacy. I have had the opportunity to review the Notice of Privacy Practices available on this website and acknowledge that I may, upon request, obtain a printed copy of the Privacy Practices from the Contact Individual below. F.Communication. I understand that communication between myself and KSVB is integral to the VCPR and increases the likelihood of a positive outcome. Communication with KSVB may occur in-person or on audio-visual calls during appointments, or via email, phone, text message or audio-visual calls outside of appointments. I may request the form of communication that works best for me. I understand that although KSVB stives to respond to me within three business days, some responses may take longer due to a high-volume of emails or calls. KSVB appreciates your understanding in this matter and requests that you reach out again if you have not heard from us in a timely matter. a.Reasonable communication. My appointment fee includes two months of reasonable correspondence following the appointment. Examples of reasonable correspondence may be one to two emails per week, a five-minute phone call to answer a short question or a pre-scheduled 30 minute “check in” call once a month. I acknowledge that KSVB may request a different form of correspondence (e.g. phone call rather than email) or a paid recheck appointment may be recommended if my questions or inquiries are extensive, excessively frequent, better answered in a different format or do not pertain to the diagnoses or treatment plans already discussed. Following the two months of included correspondence, additional paid appointment(s) may be necessary to continue ongoing treatment by KSVB. b.Pharmacy refills and prescription requests. If I request a new or refill prescription be sent to a pharmacy, I will allow at least three business days for KSVB to send the prescription. Urgent prescription authorizations may be charged an additional fee at the discretion of KSVB. G.48 Hour Cancellation and “No Show” Policy/Fees. For the courtesy of our doctor, staff and other clients, I will do my best to provide KSVB with no less than 48 hours’ notice if I am unable to keep my appointment for any reason. I acknowledge that I am responsible for paying a $100 cancellation fee if I do not cancel my appointment within the prescribed time. KSVB understands that unforeseen events occur and that I may not be able to provide 48 hours’ notice; in this case I will still notify KSVB that I will be unable to keep the appointment and work with them to reschedule if desired. I understand that if a KSVB staff member travels to my home for a scheduled house call and I am unavailable or not present within 20 minutes of my scheduled time (without notice), I am financially responsible for paying both a cancellation fee ($100) and a travel fee. Similarly, if do not log into a scheduled video or phone call within 20 minutes of my appointment time (without notice), I am responsible for paying a cancellation fee ($100). I acknowledge that habitual cancellations (three or more), even with prior notice, may result in notification that KSVB will no longer work with me or your pet. H.Late Arrivals. A 20-minute grace period is provided after the start time of my appointment. If I am running late, I will do my best to contact KSVB by phone or text to notify them. KSVB may still be able to see me and my pet, but I acknowledge that the allotted time for my appointment may be affected by the delay. The delay may prevent us from discussing everything I wished during the appointment and that a paid recheck appointment may be necessary. I understand that if the staff of KSVB is running late, especially due to traffic or an unforeseen emergency. KSVB will endeavor to contact me by phone or text if they are delayed, but I acknowledge the fact that they may not be able to if, for example, they are driving or are dealing with an emergency. In these cases, KSVB will do their best to make up this time to me, for example by extending the duration of the appointment by the missed time. I.Respectful Conduct. I acknowledge that a successful professional relationship is based on trust and mutual respect. I will treat Dr. Karen Sueda and the staff of KSVB and their representatives with the same respect and courtesy they show to me. KSVB understands that discussions of behavior problems may evoke strong and sometimes mixed or heated emotions and conflict in some clients; this is understandable and not grounds for ending a VCPR per se. However, I will do my best to discuss my concerns or disagreements with KSVB staff in a professional and civil manner. I understand that disrespectful behavior including, but not limited to physical or verbal abuse; threats or intimidation to people or animals; excessively profane or harsh language; rude or demeaning behavior toward a staff member, or offensive or discriminatory remarks will be ground for immediate termination of the VCRP.

IV. PAYMENT POLICIES AND FINANCIAL RESPONSIBILITIES (FINANCIAL RESPONSIBIILTY; PREFERRED PAYMENT; LATE FEES/NON-PAYMENT; ESTIMATES; PRICE CHANGES; PET INSURANCE; REFUNDS) A.Financial Responsibility. By initialing and checking the box below, I understand that I am responsible for the entire amount of the services, treatments and/or products provided or recommended and will remit full payment at the time of the appointment unless previously agreed upon in writing by myself and KSVB. Furthermore, I understand that charges I am responsible for may include payment for services which have not yet occurred but are included in the service fee (e.g., veterinary-client communication). I acknowledge that some charges may not be covered by insurance. I understand that I am ultimately financially responsible for all charges, including services rendered and products sold, and the failure of the insurance company to pay a claim does not negate my obligation to pay for any rendered services, treatments, products, etc. B.Preferred Payment. I have read and understand my payment options below: a.Zelle. Payment by Zelle is strongly preferred. Confirm “Send” limits with your bank PRIOR TO your appointment. i.If your bank offers Zelle, contact them PRIOR TO your appointment to ensure that the payment due at the appointment does not exceed your daily send limit. ii.If your bank does not offer Zelle, you may download the app; please do so PRIOR TO your appointment. Please note that the WEEKLY send limit is $500. If your estimated payment exceeds $500, you may use more than one payment method. 1.To avoid additional fees, we recommend sending one or more $500 DEPOSIT(S) in the week(s) prior to your scheduled appointment and paying the balance on the day of the appointment. Note that you may need to start two or more weeks ahead if your appointment costs exceed $1000. 2.Alternatively, you may use a combination of Zelle, Cash and Checks. b.Checks. Personal checks made out to “Karen Sueda Veterinary Behavior, Inc.” are accepted. However, please note that we may charge a reasonable service fee in addition to the total charge if the check is returned for insufficient funds or unable to be cashed. c.Cash. We accept cash payments only for in-person consults and not for telemedicine appointments. For safety reasons, we do not carry change with us so exact amounts are appreciated. d.Credit Cards. Credit cards (Visa, MasterCard, AmEx) are accepted with an additional $35 “per swipe” charge to off-set the processing fee. We request that you alert us prior to your appointment if you plan on paying using a credit card so we may add this fee to your estimate or invoice. e.Other forms of payment. We do not accept PayPal, Venmo, CareCredit, payment plans, partial payments, deferred payments, insurance reimbursements paid to the provider (see below), BitCoin, etc. C.Late Payment Fees/Non-Payment. I understand that full payment is due at the time of service (i.e., at the appointment) and that I will be charged a late payment fee of $50 following a one-week grace period starting from the time of service. I further understand that I am financially responsible for additional late fees of $50 accrued every two weeks until the invoice is paid in full. I understand that ongoing services such as client communication and prescription authorizations, will not occur until full payment is received unless the imminent health and welfare of the patient is in jeopardy. If I am concerned that I may not be able to pay in full PRIOR to a scheduled appointment due to an unanticipated event, I will inform KSVB so we can discuss options. If I have not made prior arrangements, once I have received services from KSVB and are unable to pay in full, I will be charged a late payment fee. I understand that inactive client financial accounts with outstanding payments for greater than 60 days may be forwarded to a collection agency or attorney for further action and that I will be responsible for all costs incurred in the process including finance charges, court costs, collection agency, and/or attorney bills, etc. Furthermore, I understand that I will be at risk of being dismissed from the care of KSVB and the VCPR will end. D.Estimates. I may request an estimate for the anticipated service(s) and/or product cost(s) associated with the behavior appointment prior to the scheduled appointment. I understand that an estimate is not a guarantee. Some of the estimated costs may be approximations (e.g. travel fee) and the total estimate may not include unanticipated costs (e.g. additional recommended training). Recommended products or services purchased from a third party (e.g. prescription medications; working with a trainer; training equipment) are not included in the estimate and I should plan for the possibility of additional expenses accordingly. E.Pricing Changes/Notification. I acknowledge that KSVB may change the pricing of their services and products at any time without prior notice. I may obtain information regarding current pricing by contacting KSVB at info@ksvetbehavior.com. If prices change and I already have a scheduled appointment, KSVB will honor the prices at the time I scheduled the appointment. If I have an estimate from KSVB, KSVB will honor prices on the estimate once, provided that the appointment is scheduled within the valid dates on the estimate. If I reschedule an appointment, I acknowledge that I will be charged the current price and not necessarily the price initially quoted/estimated. F.Veterinary (“Pet”) Insurance. KSVB will send veterinary records to the insurance provider and complete and return veterinary pet insurance forms to me when I provide them. However, I understand that KSVB does not submit insurance forms to my provider on my behalf; it is my responsibility to submit these forms. KSVB does not guarantee that my appointment or related costs will be covered by my insurance, even if my insurance carrier states that they will be. KSVB does not accept insurance reimbursements from the insurance company. I understand that KSVB will require me to pay them (KSVB) in full at the time of the appointment and have my insurance company reimburse me directly. I acknowledge that I may be charged an additional fee(s) for any forms/letters KSVB may need to write/provide to my insurance carrier on behalf of my pet beyond the standardized claim form. This fee is based on the length and complexity of the form or requested letter. If I plan to use veterinary/pet insurance, I understand that it is in my best interest to contact my provider well in advance of my appointment to determine, for example,: a.Whether behavior appointments with a board-certified veterinary behaviorist are covered b.Precisely what services and/or products are covered or excluded (e.g., appointment fee, prescriptions, training, etc) c.If any specific requirements need to be met or if there are any exclusion criteria (e.g. pre-existing conditions are excluded and what those behavioral conditions are for your pet) d.If you need to be pre-approved e.What forms need to be filled out by the veterinarian f.How and when you are reimbursed G.Refunds and Returns. If I am dissatisfied or have other complaints or concerns, I will first inform KSVB so they can help resolve the matter if possible. I understand that KSVB’s general policy is not to offer refunds or returns on services or products once provided (except when the product has a manufacturing default).

V. EFFECTIVE DATE AND RIGHT TO CHANGE TERMS OF THIS AGREEMENT A.Effective Date. This Agreement is effective on March 1, 2024. B.Right to Change Terms of this Agreement. I acknowledge that KSVB may change the terms of this Agreement at any time. If KSVB changes this Agreement, they may make the new agreement terms effective for all my information and my pet’s veterinary records that they maintain, including any information created or received prior to issuing the new agreement. If KSVB changes this agreement, they will post the new notice on their website. I am aware that I may also may obtain any new agreement by contacting their office at info@ksvetbehavior.com.

VI. CONTACT INDIVIDUAL I may contact Dr. Karen Sueda at: Karen Sueda Veterinary Behavior, Inc. 5182 Sunlight Place Los Angeles, CA 90016 Telephone Number: (213) 905-6655 E-mail: info@ksvetbehavior.com

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