I hereby authorize Appanasha Pet Clinic to initiate an electronic single debit entry withdrawal from my account with the indicated amount below for diagnostics, procedures, & care items. Furthermore, I assert that I am the owner or an authorized signer of this bank account.
NOTE: You may wish to request a voided check or in order to verifying that the routing and account number above are accurate and that the bank account is, in fact, in the name of the payer
Please sign and date the authorization below.
If I have any questions or concerns in regard to this payment, or the payment does not occur on the date or in the amount authorized, or I wish to revoke this authorization, I can call 920-725-8307
during the following business hours Monday – Friday 8a-4p.
If you should need to notify us of your intent to cancel and/or revoke this authorization, you must contact us prior to the questioned debit being initiated. Please call 920-725-8307
or email [email protected]