New Client Information

Credit Card on File

Payment is due at the time veterinary services are rendered, regardless of insurance status. We accept payment in the forms of cash, check, or credit card (Visa, MasterCard, Discover or American Express).

If you would like to charge your credit card for veterinary services, you must complete the
information below and sign the credit card authorization.
Credit Card Information/Authorization
Name*

First NameLast Name
Email*
example@example.com
Cardholder’s Name:
(As it appears on the credit card)
Mailing Address on Credit Card*

Street Address

Street Address Line 2

CityState

Zip Code
Credit Card Type:

VISAMasterCardAmerican ExpressDiscover
Credit Card Type:

DebitCredit
Credit Card Number:
Expiration Date:
V-Code:
I authorize Retama Equine Hospital, Inc. to charge the above credit card for Veterinary
Services.
Printed Name (for e-Signature)*

First NameLast Name
Today's Date*

MonthDayYear
Are you a robot?*
Should be Empty:

Credit Card on File