<p> Prestage Equine Clinic, PA 180 Peck Woods Rd. Camden, SC 29020 803-432-2733 phone and fax</p><p>Client Information Form Date:______</p><p>Owner:______</p><p>Address:______</p><p>______</p><p>Phone: home______office______cell______</p><p>Email address:______</p><p>Stable and Trainer Name:______</p><p>Credit Card Information: Card type______Card #______</p><p>Card exp date______Last 3 digits on back of card______</p><p>Signature______</p><p>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.</p><p>Horses: (continue on back if needed)</p><p>Reg. Name Barn Name Color Sex Age 1.______2.______3.______4.______5.______</p><p>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.</p><p>Signature______</p>