Recurring Payment Authorization Form – $55

Schedule your payment to be automatically charged to your Visa, MasterCard, or Discover Card.  Just complete and sign this form to get started!

If you’d like to change which credit card you are using, please contact Dominion Animal Hospital here.

Recurring Payments Will Make Your Life Easier:

It’s convenient (saving you time and postage)

Your payment is always on time (even if you’re out of town), eliminating late charges

Here’s How Recurring Payments Work:

You authorize regularly scheduled charges to your credit card.  You will be charged the amount indicated below each billing period.  A receipt for each payment will be emailed to you and the charge will appear on your credit card statement.  You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 7 days prior to the payment being collected.

  • I

  • authorize Dominion Animal Hospital to charge my credit card, indicated below, for $55 on the

  • of each month for payment of my Wellness Plan payment.

  • I understand that this authorization will remain in effect for 12 months following my sign up date. I agree to notify Dominion Animal Hospital in writing of any changes in my account information or termination of this authorization at least 30 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. In the case of a declined Transaction being rejected for Non Sufficient Funds (NSF) I understand that Dominion Animal Hospital may at its discretion attempt to process the charge again within 30 days, and agree to an additional $25 failed payment fee charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.  I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form. By signing this contract you agree to all terms and conditions concerning the Wellness Plan and that the contract may not be cancelled unless deceased pet or moving out of state and can provide proof of new residency to Dominion Animal Hospital.

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