I hereby authorize Jill Dentel, DVM of Countryside Animal Clinic of Wauseon to be the acting veterinarian in the care of my horse(s). I, as the owner/responsible party of the horse(s), agree to pay all fees in full to Countryside Animal Clinic for any and all care/services of the mentioned horse(s). Equine Dentals to be billed separately and paid directly to Jill Dentel, DVM. Payment can be made by PayPal, Venmo, Cash, or Check made payable to Jill Dentel, DVM.

I understand that if payment is not received within 30 days from the time of service, there will be a 5% finance charge applied monthly to any unpaid balances.

Please note: A 3% fee will be added to all credit card charges.

I also understand that I must call the clinic with my credit card number before scheduling an appointment.

I hereby authorize Countryside Animal Clinic of Wauseon, 11106 US 20A, Wauseon, OH 43567, to use the Credit/Debit card listed below to pay for all equine services rendered, apart from equine dentals. I hereby authorize the Credit/Debit card institution to accept the amount of such charges.

I understand that the Credit/Debit card listed below will be charged at the time of services.

A detailed statement and receipt will be mailed/emailed to you after payment is processed.

I understand that there will be a 5% finance charge monthly on any unpaid balances.

I understand that there will be a 3% fee added to all credit card charges.

I also understand that it is my responsibility to update Countryside Animal Clinic of Wauseon with any changes to the Credit/Debit card provided.

Countryside Animal Clinic of Wauseon understands that this information is confidential and will keep this information private. Thank you for your cooperation in our billing procedure.