Genesee Valley Equine Clinic

Payment Form

GVEC strives to offer you, our client, the latest in equine medicine. We ask that payment for our services be made at the time of the appointment or arranged ahead of time by securely storing a charge card with us. We offer three payment options, one of which is sure to fit into your individual bill paying system.

Name *

First

Last

Payment Options *

Option 1 - Charge my card after each visit.
Option 2 - Charge my card at the end of each month.
Option 3 - Pay by cash, check, or credit card at time of the appointment.

Please Choose an Option

Card Type

MasterCard
Visa
Discover
American Express

Please complete if you are choosing to leave a card number on file with us. Note: Carecredit cards cannot be saved on file. Please call the office for further information.

Cardholder's Name

Cardholder's Billing Address

Please do NOT write your card number on this form. Instructions to call the clinic will be included in the confirmation message after submitting this form. Thank you!

Electronic Signature *

First

Last

By completing this form, I authorize the above payment option.

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