Southern Equine Associates, L.L.C.

Your Name: *


Billing Street Address *


Zip Code *


Account Number *


Payment Amount *


Credit Card Type *
American Express Visa Mastercard

Credit Card Number *


Expiration Date (MM/YY) *


Security Code *


Customer Code (If available)


I accept the following policy: Any person who brings in a horse(s) (hereafter known as Agent-including trainers) that are owned by someone other than themselves (hereafter known as Client), are entirely responsible for any bills that are accumulated on the horse(s) during the visit &/orhospital stay should the owner not pay (for any reason) and specifically if the bill becomes 60 days past due. Agents MUST have permission to have a Client's horse examinied/treated PRIOR to making an appointment. Credit Card Payment Agreement forms are available in our office for Agents to give to their clients so that Clients credit cards may be charged after services are performed/medications dispensed. If the Client denies the charges to the credit card company, Agents will be responsible for collecting and/or paying the bill on the horse they brought in. Agents are responsible for providing Southern Equine Associates, LLC with correct address information on the Clients. Bringing a Client's horse into the clinic and/or paying this bill consitutes Agents agreement to the above terms. *