Credit Card Authorization Form

I hereby authorize Massie Equine Veterinary Clinic & Healing Center to keep my credit card and signature on file and to charge my account for services rendered. Credit card information is confidential and kept secure. This authorization is incorporated by reference to the Massie Veterinary Services Fee Agreement. Pursuant to the terms of the Fee Agreement, Section 4: "If payment for services rendered is not received in full within 30 days of service, Client authorizes Massie Veterinary Services to apply the charges to my credit card on file."

By providing my credit card number and signature, I authorize Massie Equine Veterinary Clinic & Healing Center to charge my credit card for an account balance that is outstanding 30 days past the date of service.

Initial

Choose ONE option

I choose automatic credit/debit card payments at time of serviceI choose a detailed invoice to be sent prior to any charges applied to the below listed credit card. You must inform Massie Equine Veterinary Clinic to charge the card once you review the received invoices.

This authorization is revocable at any time upon written notification to Massie Veterinary Services, with written confirmation of receipt from Massie Equine Veterinary Clinic & Healing Center.

Authorized Cardholder Signature

Print Name

Date

Name on Card

Billing Address

Zip Code

Card Number Last Four

3 digits

Expiration

Email Address for Receipt

example@example.com