Consent and Signature
By signing below, I consent to Riverside Animal Hospital running the card above on the date specified above. I understand that I am responsible for payment of all services rendered in full. I understand that the staff at Riverside Animal Hospital will call me at the phone number(s) listed above on the date listed above before running my card. If I do not respond within 24 hours, I understand that the staff at Riverside Animal Hospital will run my card for the full amount of my balance, and will email my receipt to the email listed above.