Payment Option and Authorization Form Name(Required) First Last Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneCellEmail(Required) Charge my credit card at the time of service for the total amount due. I understand that processing will take place as early as the day after treatment.I, the undersigned, understand that my credit card will be charged for each visit and any supplies or medications ordered by myself or an authorized agent (trainer, barn manager), unless another form of payment is provided at the appointment.We accept (please select one):(Required) Visa MasterCard American Express Discover Care Credit Credit Card (Last 4)(Required)Expiration(Required) Month Day Year CCV(Required)Billing Zip Code(Required)Signature(Required)Confidential: The information provided on this form will be used only to pay the balance owed on the account to Mid-Rivers Equine CentreCAPTCHA