Texas A&M Veterinary Medical Diagnostic Laboratory
PO Drawer 3040, College Station, TX 77841
Billing Phone: 979-458-3207 • Fax: 979-458-3260 • Email: Payments@tvmdl.tamu.edu
Clinic/Company or Client Name: Owner: _______________________
*SSN or Federal Tax ID (required by State of Texas
9
)
Ship to Address:
City: County: State: _________ Zip Code:
Ph: Fax: Reporting E-Mail:
Billing Address (if different):
City: County: State: _________ Zip Code:
Ph: Fax: Billing E-Mail:
Note: As an account holder with TVMDL, all billing correspondence and reports will be sent via e-mail. You will also receive
secure online access to your client portal and have access to case reports, invoices, and online bill payment.
How did you hear about Texas A&M Veterinary Medical Diagnostic Laboratory (TVMDL)?
Online ____ Other Veterinarian ____ Other Laboratory ____ Trade Show ___________________________ Other: ________________________
Terms & Conditions:
1) Services supplied by TVMDL are subject to the terms and conditions set below. Any modification of such terms will void this form.
Submitting the application does not guarantee approval.
2) The balance of each Final Monthly Invoice is due by the last day of each month to avoid finance charges. Payment must be received
prior to the next billing cycle, which is the first working day of each month.
3) Finance charges of 0.833% per month (10% annually) are accessed on all charges older than 30 days. Your account will be
suspended if your balance becomes past due. It is your responsibility to keep our files updated with your most current billing address
and phone number. TVMDL must be notified of change of ownership of clinic.
4) Payments are accepted online or over the phone with Visa, MasterCard, Discover, or American Express; or by check or money order
through the mail. Please mail payments to the College Station location only.
5) Payments are applied to the oldest charges first.
6) If your payment does not specify an account number, accession number or final invoice number, it may be returned to
you.
7) TVMDL reserves the right to revoke your charging privileges at any time.
8) Final monthly invoices are only delivered by e-mail. The final monthly invoice will be delivered to the billing email address
provided on this form.
9) State of Texas Government Code 403.031(c), 2107.004, and 403.055 requires state agencies to collect this information in the event of
delinquency.
I have read, understand and accept the terms stated within this form, and have provided true information to the best of my knowledge.
By signing this form, I/We guarantee payment for all services received.
Authorized Signature
Title Date
*This form cannot be processed without a signature and Federal Tax ID/Social Security Number.
Fax or mail your completed form to TVMDL.
Visit our website at http://tvmdl.tamu.edu for pricing, sample requirements and testing turnaround times.
