Client Account Registration InstagramThis field is for validation purposes and should be left unchanged.Name(Required) First Last Home PhoneCell Phone(Required)Work PhoneEmail(Required) Emercency Contact(Required)Emergency Contact Phone(Required)I authorize the following individuals to make decisions regarding my animals’ care(Please list the barn owner/manager/trainer here if the animals are not kept on your property. Please list a friend or family member that can authorize veterinary treatment if you cannot be reached.) Patient Information(Required)Please list name, age, species, breed, etc.Terms(Required)Payment Options/Billing Policy Payment is due at time of service. We accept payments in cash, check, Visa, Mastercard, Discover Card, American Express and Care Credit. Upon receipt of the completed Credit Card Authorization Form, we will charge your credit card for veterinary services not paid on the 30th of the month. Past Due Accounts Any balances that are 30 days past due will automatically be charged to the client’s credit card at the end of the monthly billing cycle. Statements that summarize outstanding invoices are mailed at the end of each month. Returned Checks A fee of $35.00 is charged for each check returned for non-payment. Consent for Care I hereby authorize All Points Equine to perform veterinary services on my horse(s). I understand that fees are payable at time of service. Those fees are payable with cash, check, credit card or care credit. Accounts not paid in full will be charged a finance charge of 1.75% per month (21% annual) on the balance and no further services will be provided. If legal action is necessary to collect unpaid fees, all costs of collection will be charged to the debtor. I agree to the Terms of ServiceSignature(Required)
