Bayberry Equine New Client and Payment Policy Form

New Client and Payment Policy Form
Client Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Authorized Agent for Veterinary Care (optional)
This person is allowed to make veterinary care decisions for my horse(s) on my behalf

Horse Information

	Name	Show Name	Birth Date (use 01/01/yyyy if exact date unknown)	Breed	Sex	Color	Insured?
Horse 1
Horse 2
Horse 3
Horse 4
Horse 5
Horse 6
Horse 7
Horse 8
Horse 9
Horse 10

Horse Location and Address - please specify if your horses are in more than one location
Payment Policy

Please acknowledge each statement of our financial payment policy below
I understand and agree payment is due in full at time of service.*
I understand and agree the first appointment's payment must be made with a credit card, cash, or Venmo payment at the time of the appointment. *
After the first appointment, I understand and agree my credit card on file will be automatically charged within 1-5 business days of receiving an invoice for veterinary services, unless I am present at the appointment and provide another form of payment (check, cash, or Venmo is accepted). *
I understand and agree my credit card will be kept on file in an electronically secure system.*
I understand and agree veterinary services will not be provided to a client with a delinquent account. *
I hereby authorize Bayberry Equine LLC to provide care to my horse(s) in my absence at the request of my authorized agent listed above. *
Signature*

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By signing this document, I certify that the above information is correct to the best of my knowledge and I will abide by the financial policies agreed to above.
Printed Name*
Date*

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New Client and Payment Policy Form