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 if payment is not received within 30 days from time of service, there will be a 1.5% finance charge monthly on any unpaid balances.

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 1.5% finance charge monthly on any unpaid balances.

I understand that it will be 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.