New Client Form

Name on the Account

Billing Address *

Billing Address

City

State/Province

Zip/Postal

Country

Cell Phone *

Alternate Phone

Billing Email Address *

Name on Credit Card *

Credit Card Number For Our File *

Credit Card Expiration Date *

CVV / CCID (security code) *

Conditions: *

* I authorize the above card to be used by VEI for payments toward invoices on services rendered. * I understand that any past due invoices will be subject to finance charges that I am responsible for.

Barn Where Horse Is Kept

Authorized Agent (trainer/barn owner/lessee):

I authorize my agent to make appointments and order medication for my horse and give him/her permission to charge such appointments/medications to my credit card. *

Yes

Horse Demographics:

Name: *

Breed: *

Color: *

Age: *

Type: *

Discipline: *

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