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:

I authorize charging my credit card on file for all invoices as they are completedI authorize charging my credit card on file for all invoices up to $__________ as they are completed. I request confirmation prior to charging any invoices totally over the above dollar amount.I authorize use of my credit card on file however I will provide confirmation by phone, text, email or in person on each invoice prior to charging.

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