We require all clients to have a credit card on file.

Please fill out this credit card form prior to our veterinary visit with your horse.
Please check one of the following:
Billing address
Address of barn where the horse is located
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My signature states that I hereby authorize Bur Oak Veterinary & Podiatry Services, LLC to keep my credit card and signature on file and to charge my account for services rendered. Credit card information is confidential and kept secure. This authorization is incorporated by reference to the Bur Oak Veterinary & Podiatry Services agreement. Pursuant to the terms of the Fee Agreement, Section 4: “If payment for services rendered is not received in full within 30 days of service, Client authorizes Bur Oak Veterinary & Podiatry Services to apply the charges to my credit card on file.” By providing my credit card number and signature, I authorize Bur Oak Veterinary & Podiatry Services to charge my credit card for an account balance that is outstanding 30 days past the date of service. This authorization is revocable at any time upon written notification to Bur Oak Veterinary & Podiatry Services with written confirmation from Bur Oak Veterinary & Podiatry Services. We accept Master Card, Visa, Discover and American Express.

Payment Terms:
Payment is due at the time service is rendered. If you would like to set up an in house account we must have a current card on file first. Approval will come within 30 days.

Unless otherwise requested, all invoices, medical reports, and diagnostic images shall be provided electronically.

Clients may elect for automatic payments (see attached form) Automatic payments shall enable Bur Oak Veterinary & Podiatry Services to charge the current balance due at time of service to the credit card on file. An invoice will be sent electronically with payment confirmation.

If payment for services rendered is not received in full within 30 days of service, Client’s credit card will be charged as listed in following agreement for the full amount owed and any interest aquired.

Clients may pay by personal or business check. Client is responsible for all bank charges incurred by Bur Oak Veterinary & Podiatry Services if a check is returned, in addition to a $36.00 service fee (bank fee of $25.00 plus an in- house $11.00 office fee)

Unpaid balances are subject to the following: I, the undersigned, agree that should ANY payment or the full amount of the sum stated above become overdue more than 5 days from the above agreed time of payment or payments, the entire balance shall be considered in default and become due and payable with service charges. From the date of default, service charges will be at the rate of 1.5% per month, which is an annual percentage rate of 18%. I further acknowledge that if my account remains in default it may be sent to a collection agency and I, the undersigned, do agree to accept responsibility for payment of additional collection fees equaling 35% of the total balance due, or at a minimum of $250 in addition to what is owed. I certify that I have read the forgoing agreement and understand the terms and conditions thereof before signing below. The undersigned is also responsible for any legal fees incurred by Bur Oak Veterinary & Podiatry Services during collection of the past due account.

Bur Oak Veterinary & Podiatry Services LLC has the right to refuse service at any time. Bur Oak Veterinary & Podiatry Services may elect not provide service to Clients with accounts that are past-due beyond 60 days.

Client shall immediately notify Bur Oak Veterinary & Podiatry Services if he/she is unable to comply with the terms of this agreement. Bur Oak Veterinary & Podiatry Services LLC reserves the right to waive fees and modify payment deadlines on an individual, case-by-case basis at its sole discretion. Such an agreement shall be effective upon the execution of a separate, written agreement, signed by both parties.

Except as otherwise provided in this document, this agreement may be modified, superseded, or voided only upon the written and signed agreement of Bur Oak Veterinary & Podiatry Services LLC and Client. Further, the physical destruction or loss of this document shall not be construed as a modification or termination of the agreement contained herein.

The rights and obligations of the Parties under this Agreement shall be governed by the internal substantive law of the States of Arizona, Florida, Kentucky, North Carolina, Ohio, Oklahoma, Tennesee, Texas and Virginia applicable to contracts made and to be performed in that State, without giving effect to the principles of conflicts of laws. For the purpose of jurisdiction and venue for all purposes of this Agreement shall be Fayette County, Kentucky. If any legal action, arbitration or other proceeding is brought for the enforcement of the agreement, or arises out of an alleged dispute, breach, default or misrepresentation relating to any of the terms of the agreement, Bur Oak Veterinary & Podiatry Services shall be entitled to recover reasonable attorney’s fees and other costs in that action or proceeding in addition to any other relief to which it may be entitled. Client has provided Bur Oak Veterinary & Podiatry Services with a valid credit card number and hereby authorizes Bur Oak Veterinary & Podiatry Services, LLC to charge the credit card for services rendered in accordance with the terms of this agreement. By signing below you are consenting to the examination and treatment of your equine and or pet and acknowledging that you will be financially responsible for the fees incurred for services rendered by Bur Oak Veterinary & Podiatry Services, LLC. You may request an estimate of anticipated fees before services are performed. There are no guarantees or assurances of the outcome from any examination or treatment provided. Bur Oak Veterinary & Podiatry Services LLC may be labeled in this document as BOVPS.

If you would prefer to print out and complete the required form and email it to info@buroakveterinary.com, please click the pink tab below