Cover
Home
About
Composite Shoes
Supportive Therapies
Payment
Respective Responsibilities
New Client Introduction Form
Client Portal
Blog
Menu
Cover
Home
About
Composite Shoes
Supportive Therapies
Payment
Respective Responsibilities
New Client Introduction Form
Client Portal
Blog
Credit Card Authorization Form
Name On Card
*
First Name
Last Name
Card Type
*
MasterCard
American Express
Visa
Discover
Credit or Debit Card?
*
Credit
Debit
Credit Card Number
*
Expiration Date
*
Security Code
*
Cardholder Zip Code
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Call or text with amount for authorization before running card?
*
A reminder that payment is due on the day of service, if you can't be reached for authorization same day, late fees may apply until authorization is received.
Yes
No
If no authorization required, would you like to specify a maximum transaction amount?
Digital Consent Signature:
*
By electronically signing your name in the box below you are authorizing Big River Equine, LLC to retain your card information for payment processing.
Thank you!