I give permission for the doctors and staff at VECC to evaluate and initiate emergency treatment if necessary. I, the undersigned, assume financial responsibility for all charges incurred and agree to pay all such charges at the time services are rendered or arranged prior to examination and/or treatment. I also understand that out of state checks or third party credit cards are not accepted. I am responsible for interest and collection fees on an unpaid balance. I am 18 years of age or older.