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KEITH F. BRADY DVM JEFFREY S. BESHEAR DVM LAUREN M. GALLASPY DVM TIFFANY M. SNELL DVM 6539 Gordonsville Road Keswick Virginia 22947 Office 434 951-9225 Fax 434 951-9230 New Client Info Sheet Name Home Phone Work Phone Cell Phone Email Mailing Address Address of Stable Animal Information Name Age Color Breed How did you hear about us WWW.OLDDOMINIONEQUINE.COM Sex Stabled At Billing Policy Please select one payment option AND provide information for one credit card to be kept on file for your client account. Payments must be received no later than 30 days after the billing date or your credit card will be charged for the full amount indicated on your bill* Payment Options Select One Charge my credit card automatically on the last business day of each month. Bill me. Outstanding balances will be applied to credit card after 30 days. Pay at time of service with cash or check. Outstanding balances will be applied to credit card after 30 days. Credit Card Information Required For All Client Accounts Name as it appears on card Address Phone Driver s License or Social Security Visa MasterCard Discover American Express Credit Card Number Expiration Date Signature Date. Payments must be received no later than 30 days after the billing date or your credit card will be charged for the full amount indicated on your bill* Payment Options Select One Charge my credit card automatically on the last business day of each month. Bill me. Outstanding balances will be applied to credit card after 30 days. Pay at time of service with cash or check. Bill me. Outstanding balances will be applied to credit card after 30 days. Pay at time of service with cash or check. Outstanding balances will be applied to credit card after 30 days. Credit Card Information Required For All Client Accounts Name as it appears on card Address Phone Driver s License or Social Security Visa MasterCard Discover American Express Credit Card Number Expiration Date Signature Date. Payments must be received no later than 30 days after the billing date or your credit card will be charged for the full amount indicated on your bill* Payment Options Select One Charge my credit card automatically on the last business day of each month. Bill me. Outstanding balances will be applied to credit card after 30 days. Pay at time of service with cash or check. Outstanding balances will be applied to credit card after 30 days. Credit Card Information Required For All Client Accounts Name as it appears on card Address Phone Driver s License or Social Security Visa MasterCard Discover American Express Credit Card Number Expiration Date Signature Date.

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