Client Information Sheet

OUR POLICY:  Payment is due at the time services are rendered.  We accept Cash, Check, Visa, MasterCard, AmericanExpress, Discover and CareCredit. If you are unable to be present during your horse(s) or farm animal(s) appointment, a credit card number must be kept on file with us to post any charges that you incur to that card.  In the event that payment is not made at the time of service, a $15.00 service charge fee or 2.0% (24% PER aNNUM), whichever is greater, will be added to any account over 30 days past due. There is a $35.00 fee for any check returned to us for Not-Sufficient Funds.

To avoid service fees, a great payment option is CareCredit.  Applying for CareCredit is simple and quick.  You can apply online at or give them a call at 800-365-8295.  There are no annual fees and you can use your card for your veterinary needs as most veterinary clinics and hospitals are now accepting CareCredit.  With CareCredit there is no down payment and CareCredit automatically offers six months same as cash for balances $200.00 or more.  For balances $600-$1,250 – twelve months same as cash and for balances over $1,250 – eighteen months same as cash! Now that’s a deal! Check it out today!

Name *
Mailing Address *
Mailing Address
Physical Address if different from above
Physical Address if different from above
Home Telephone Number *
Home Telephone Number
Cell Phone Number *
Cell Phone Number
Work Telephone Number *
Work Telephone Number
Spouse/Significant Other Name
Spouse/Significant Other Name
Significant Other Telephone Number
Significant Other Telephone Number
By submitting this form, should you use the services of Dominion Veterinary Service PC dba Dominion Equine Clinic, you agree to pay for all services rendered and agree to the terms stated below.
In the unfortunate event that your unpaid account is referred to an attorney for collection, the undersigned person(s) promise and agree to pay all collection costs including attorney fees of 33 1/3% of the principal amount due and owing when turned over for collection. Further, on any overdue balance, the undersigned does further agree to pay interest at a rate of 2% per month (24% per Annum) on the unpaid balance from the date that the account went into default until paid. I authorize photocopies of this form to be as valid as the original. In the event this matter is turned over for collection, I hereby expressly give permission for my current employer(s) to provide verification of my said employment to this office, or their attorney, Tiffany & Tiffany, P.L.L.C