CREDIT CARD PAYMENT AUTHORIZATION FORM

By signing this form, you give Advanced Equine of the Hudson Valley permission to charge your credit card on file for all invoices on or after the indicated date.

Please complete the information below:

    I (full name)

    authorize Advanced Equine of the Hudson Valley to charge my credit card provided for invoices on or after (date) . This payment is for veterinary services and medications provided for animals I own or are financially responsible for per the separate client registration agreement.

    Please check one option below:

    $

    Billing

    Address

    I certify that I am an authorized user of the provided credit card and I will not dispute the payment with my credit card company so long as the transaction complies with the terms indicated on this form

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