Name: Knoellwood Equine
Address: S
Telephone: +1-(845) 978-3828
Price range: $$

It is our practice policy to require a valid credit card on file - this will ONLY be used in the event that your account balance is over 30 days past due, or if you request it to be used for general billing.

Please complete all fields. You may cancel this authorization at any time (in writing) by notifying info@knoellwoodequine.com. This authorization will remain in effect until canceled.
Name on Account*
Card Type*
- American Express
- Care Credit
- Discover
- MasterCard
- Visa
Credit Card Number*
CVV Code*
Credit Card Expiration Date*
Card Billing Zip Code*
As the owner or authorized user of the above credit card, I authorize Megan Knoell, DVM, PLLC (dba Knoellwood Equine) to charge this card for any account balance for veterinary services that is 30 or more days past due.
I understand that past due accounts will also incur a late fee, which is calculated monthly.
I understand that my information will be stored securely within Square (credit card processor)
Authorized Signature for Card on File*
Toady's Date*
MM slash DD slash YYYY
- Please check here if you would prefer to automatically have your statement balance charged to the card on file at time of service
Comments
This field is for validation purposes and should be left unchanged.

Credit Card Information