Prestage Equine Clinic, PA

Prestage Equine Clinic, PA 180 Peck Woods Rd. Camden, SC 29020 803-432-2733 phone and fax

Client Information Form Date:______

Owner:______

Address:______

______

Phone: home______office______cell______

Email address:______

Stable and Trainer Name:______

Credit Card Information: Card type______Card #______

Card exp date______Last 3 digits on back of card______

Signature______

Method of Payment (check one of the following O Cash or Check payment at time of service O Automatically bill credit card at time of service. An itemized bill will be sent at the end of the month.

Horses: (continue on back if needed)

Reg. Name Barn Name Color Sex Age 1.______2.______3.______4.______5.______

I understand that I am responsible for any and all charges acquired during the treatment of my animals. Payment is due at the time services are rendered. Any payment plan or agreement must be previously discussed with the veterinarian.

Signature______