Remote Payment Form
Pet Owner / Legal Guardian Information
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Pet Information
Patient Name
*
Patient Breed
*
Patient Species
*
Patient Number if Known
*
Payment Information
There will be a 5% interest assessed over Invoice Value
*
This is a service fee assessed on an invoice for the time and cost of processing the transaction, facilitating the financing of the proposed plan by a third company other than the hospital's regular credit/debit merchant or cash payment, this charge helps compensate for the cost incurred for the time and hospital's resources spent processing the financing charge through a third party merchant other than the one offered on our facility.
Payment Authorization Statement
*
I authorize Paws and Claws Medical Center, Inc (PACMC). to a one time charge for the full amount owed to my credit card provided today, I agree to have available funds in amounts sufficient to pay for all accrued amounts, as well as, any other payment obligations I willingly and knowingly accrue with PACMC for this same Service/procedure. (PACMC accepts VISA OR MASTERCARD ONLY, NO AMERICAN EXPRESS, sorry for the inconvenience). I agree to indemnify and hold Paws and Claws Medical Center harmless from any and all third party claims, liability, damages, expenses and costs (inclusive of bank charges and attorneys fees) caused by or arising from lack of funds or your violation of the agreement contained herein.
Total Payment Amount
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( X )
USD
Description
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Driver's License Picture
*
Should be Empty: