Financial Policy Form / Authorization for Credit Card Use Step 1 of 250%Thank you for choosing Martinez Animal Hospital. Our primary mission is to deliver the best and most comprehensive veterinary care available for your pet. An important part of the mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options. MartinezcAnimal Hospital requires payment in full at the end of your pet's examination and/or at the time of discharge. Please be aware we require new clients and re-activation clients to pre-pay for their exam fee ($75). MAH requires payment at the time of service. We accept the following forms of payment: Cash - So old school, but yes, we'll be happy to take it Credit CardsAll major credit cards (American Express, Discover, Visa, Mastercard) Apple Pay CareCreditPlease note, credit cards may be kept on file to use with your authorization to expedite check-out. If this is a service you would like to utilize, please fill out the Credit Card Authorization Form. **All services and charges are verified prior to payment processing**Additional Policy Information: Martinez Animal Hospital requires a pre-payment of the exam fee at time of scheduling an appointment for new clients and reactivation clients. In the event you do not reschedule or cancel an appointment within 24 hours of your scheduled appointment time, there will be a fee of $75 for a missed doctor’s appointment and a fee of $46 for a missed nursing appointment. A credit card deposit is required for clients who have missed or cancelled more than 2 appointments in a calendar year without 24 hours notice. For inpatient exams, if you do not arrive within your scheduled drop off time, we reserve the right to reschedule your appointment and charge our missed appointment fee. In the chance a payment plan is approved, there will be additional required paperwork to fill out. If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your pet. Rates and charges as of February 2022 and are subject to changeSignatureDate MM slash DD slash YYYY Authorization for Credit Card UseCustomer NameName on Card First Middle Last Billing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Card Type Visa Mastercard Discover AmexCredit Card NumberExpiration DateCVV (Code on back of card)Amount to charge up to (Dollar amount)I authorize ___Martinez Animal Hospital___ to charge the amount listed above to the card provided herein. I agree to pay for this purchase in accordance with the issuing bank cardholder agreement.Cardholder- Please sign and dateSignaturePrinted NameDate MM slash DD slash YYYY