Consent Form

Client/Owner Name(Required)

First Last

Client/Owner Phone(Required)

Client/Owner Email(Required)

Client/Owner Address(Required)

Agent Name

First Last

Agent Phone

Agent Email

Authorize Dr. Lindsay Hower of Mt. Laramie Veterinary Services to perform veterinary services on my horse(s) and other animals that I currently own, or will own in the future.
Authorize the agent/trainer/caregiver listed above to order veterinary services on my behalf.
Agree to pay the charges associated with the veterinary services and goods rendered to my animal(s).

I also consent to the following:

Payment is due at the time of service. If owner of animals is not present at the appointment, a valid credit card must be kept on file to be charged at the completion of services. Monthly billing arrangements must be set up in advance and a valid credit card must be on file.
Accounts not paid in full within 30 days will be charged 3.5% interest per month on the balance due, and any additional services must be charged to a valid credit card or paid via cash or check at the time of service.
If an account is unpaid by more than 60 days or $500.00, Mt. Laramie Veterinary Services reserves the right to decline further services and automatically charge the credit card on file. If legal action is necessary to collect unpaid invoices, attorney fees will be charged to the debtor.

Credit Card Type

Visa, Mastercard, Discover

American Express

Name on Card

Credit Card Number

Visa, Mastercard, Discover

Credit Card Number

American Express

Expiration Date

Example: 03/2023 or 03/23

3/4 Digit Code

Charge

Do you agree to have your card charged automatically and have the receipt emailed to the address on file?

I agree

Max charge dollar amount

Signature(Required)

Date(Required)