Northeast Pennsylvania Equine Clinic, L.L.C.

Ellen L. Johnson, D.V.M.

4326 State Route 1001• Thompson • PA • 18465

Tel: 570-727-2868 • Fax: 570-727-2935

Client Credit Agreement

  • Payment in Full is expected at the time of service via Cash, Check, Master Card, VISA, Discover, American Express or electronic check withdrawal. CareCredit may be extended at the doctor’s discretion.
  • Secure payment arrangements must be made in advance with boarding owners who will not be present at the time of service by completing this form prior to services being rendered. Clients who leave a currently dated check made payable to N.P.E.C. with open amount to cover agreed upon services, will receive a $5.00 discount off each invoice.Boarding clients will be allowed the opportunity to make payment within 10 days of date of service. After 10 days, Northeast Pennsylvania Equine Clinic, LLC will charge the unpaid balance may be charged to the owner’s credit card or checking account.
  • An automatic checking account withdrawal plan on a mutually agreeable schedule is also available when necessary to assist clients in paying for emergency services.
  • An outstanding balance over 30 days will be subject to a 2% monthly finance charge or a minimum of a $5.00 monthly carrying charge.

Please complete the all sections below and provide bank information and at least one additional form of payment. Thank you in advance for your cooperation!

Personal Information:

Name: ______

Address: ______

Home #:______Work #: ______Cell #: ______

SSN: ______-______-______DOB: _____/_____/______Driver’s License #: ______

Name & Address of Employer: ______

______

Emergency Contact & #: ______

E-Mail Address: ______

Credit Card Information:

Primary Card

Card Type: ______Account No. ______Exp. Date: _____/_____ CSC: ______

Billing Address: ______

(If different from above.)

NPEC Client Credit Agreement

Secondary Card

Card Type: ______Account No. ______Exp. Date: _____/_____ CSC: ______

Billing Address: ______

(If different from above.)

Bank Information:

Checking Account Holder(s) Name: ______

Bank Name: ______

Bank Address and Phone #: ______

9-Digit Routing Number ______Account No. ______

Debit Card No. ______Exp. Date: _____/_____ V-code: ______

CareCredit Account Information:(not always available – pending credit approval)

CareCredit

Account No. ______Credit Limit: $______

I agree to pay my exact balance in full via CareCredit.

Estimated Total Bill: $______Plan Type: ____ 6-month* ____ 12-month* ____ 24-month†

*Interest Free †13.9% APR

Doctor Signature: ______

Client Signature: ______

Automatic Payment Schedule Agreement:

I agree to pay Northeast Pennsylvania Equine Clinic, LLC the balance on my account of $______plus 2% per month finance charge by authorizing electronic check withdrawalsout of my bank account specified above, according to the following:

Payment

Method:  Checking (e-check) Debit Card Primary Card Secondary Card

Amount: $______Schedule: Weekly Bi-weekly Monthly

I accept the terms of this notice and understand that I am legally liable for the above payments to be paid in full as agreed upon, and hereby authorize Northeast Pennsylvania Equine Clinic, LLC to perform a credit check prior to services being rendered. If this account has to be referred to a collection agency, an attorney or small claims court, I will be held responsible for all reasonablefees.

Signature: ______Today’s Date: ______

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