CLIENT FORM CC | baileysequine

Client Information
-- Credit Card Authorization --

This agreement is by and between Baileys Equine, Inc and the client named below for veterinary services.
This contract shall apply to any and all services provided and products sold by Baileys Equine, Inc.

First name

Last name

Name on the Account (if different)

Phone

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Trainer's Name (Authorizing Agent - This representative is hereby authorized to approve veterinary care to my horse(s) in my absence and I am accepting financial responsibility).

Trainer's Phone Number

Credit Card #

Exact Name on Card

Billing Zip Code

Expiration

Security Code

By submitting this form, I am authorizing that services rendered may be charged to the credit card listed above for the current balance due. An invoice will be sent to the email address you have provided prior to the card being charged.

Please enter any comments or questions here associated with your new client account.

Your Signature

Select a date

Client Information
-- Credit Card Authorization --

This agreement is by and between Baileys Equine, Inc and the client named below for veterinary services.
This contract shall apply to any and all services provided and products sold by Baileys Equine, Inc.

Baileys Equine, Inc.
31103 Rancho Viejo Rd, Suite D2030
San Juan Capistrano, CA 92675

Phone: 949-212-2530
Fax: 949-661-1766
manager@baileysequine.com
alisondvm@baileysequine.com

Client Information -- Credit Card Authorization --

This agreement is by and between Baileys Equine, Inc and the client named below for veterinary services. This contract shall apply to any and all services provided and products sold by Baileys Equine, Inc.

Baileys Equine, Inc. 31103 Rancho Viejo Rd, Suite D2030 San Juan Capistrano, CA 92675

Phone: 949-212-2530 Fax: 949-661-1766 manager@baileysequine.com alisondvm@baileysequine.com

Client Information
-- Credit Card Authorization --

This agreement is by and between Baileys Equine, Inc and the client named below for veterinary services.
This contract shall apply to any and all services provided and products sold by Baileys Equine, Inc.

Baileys Equine, Inc.
31103 Rancho Viejo Rd, Suite D2030
San Juan Capistrano, CA 92675

Phone: 949-212-2530
Fax: 949-661-1766
manager@baileysequine.com
alisondvm@baileysequine.com