Chilled Semen Credit Card Authorization

Chilled Semen Credit Card Authorization
I, the undersigned, do authorize Olney-Sandy Spring Veterinary Hospital to charge my credit card for the processing and shipment of chilled semen. This will include Federal Express fees to ship the chilled semen to its destination. (Visa, MasterCard and Discover only)
How many semen shipments are we doing? (Each shipment will incur a separate charge)*

OneTwo
By signing below I understand and agree to all of the conditions stated above.
Today’s Date*

MonthDayYear
Semen Information
Owner's Name*

First NameLast Name
Dog’s Call Name
Payment Information
Name on Card
Credit Card Number
Expiration Date
Security code
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Phone Number*
Email address*
Signature of card holder

Clear
Please fax or email this form to us once completed.

*This information will not be shared and will be destroyed after the final shipment.
Should be Empty:

Semen Information