Payment is due at the time services are performed. For your convenience we accept cash, checks, Visa, MasterCard, and American Express. We offer to automatically charge your card and send a statement for your records. If you would like to have your credit card information kept on file, please print this document and provide the required information (use the print icon at the bottom of the page). You may mail the completed form to the address below or give to the Doctor at your visit.
I, __________________________________________, give permission to Cypress Equine Services, Inc., to keep my credit card information on file. I understand that this form will be filed in a secure location. I authorize Cypress Equine Services, Inc. to charge this card for amounts invoiced.
_____Visa _____MasterCard _____American Express
Cardholder Name ____________________________________________________
Card Number _______________________________________________________
Expiration Date _____________________
Billing Address (if different than on file) __________________________________
Authorized Signature _______________________________________________