Prescription Refill Request

I understand that payment in full is due at the time of service. I agree to assume financial responsibility for all professional fees, and agree to pay CVCA when services are rendered. I understand that a fee of $35.00 will be incurred for all returned checks and a service fee of 1.5% will be charged on any unpaid balance. CVCA may also recover reasonable attorney’s fees and court costs incurred as a result of my failure to pay in accordance with this authorization.