Chilled Semen Shipment Information Form and Credit Card Authorization Form

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Chilled Semen Shipment Information Form

This form is to be completed by the female breeding dog owner BEFORE the semen will be shipped. Shipping costs are usually paid by the female breeding dog owner. The semen owner is ultimately responsible for all charges if the Credit Card number used is declined.

Date Semen is to be shipped:
Date Format: MM slash DD slash YYYY
Stud Dog- Owner's Name:
First Last
Stud's Registered Name:
Stud's Breed:
Stud's Registry & Number
Stud's Call Name:
Female Breeding Dog- Owners Name:
First Last
Female Breeding Dog's Registered Name:
Breed:
Registry & Number:
Call Name:
Shipping To: (Where?)
Hospital or Clinic Name:
Veterinarian's Name:
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Send Receipt to:
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone

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Chilled Semen Credit Card Authorization Form

Once completed, this form will be printed by the staff at Summerfields Animal Hospital. A copy of the credit card, a valid driver's license and finalized signature authorization is required.

Please check the boxes below to acknowledge authorizaton of the statements below.*
- I, the undersigned, do authorize Summerfields Animal Hospital to charge my credit card for the shipment and processing of a chilled semen shipment.
- I understand that the charges applicable are for semen preparation and packaging, and I will be charged to the below documented credit card by Summerfields Animal Hospital.
- I also authorize Summerfields Animal Hospital to put my credit card number on the Federal Express air-bill to pay the charges to ship the package to it's destination. ***THERE WILL BE TWO SEPARATE CHARGES TO YOUR CARD, ONE FROM SUMMERFIELDS ANIMAL HOSPITAL AND ONE FROM FED EX.***
- By signing below I understand and agree to all of the above statements.
Today's Date*
Date Format: MM slash DD slash YYYY
Credit Card Number*
We Accept MasterCard, Visa,
Name on Credit Card
First Last
Credit Card Expiration Date*
Date Format: MM slash DD slash YYYY
Three digit security code on back of credit card*
Contact Phone Number
Your Name:
First Last

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Wednesday	7:30am – 7:00pm
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Sunday	2:00pm – 7:00pm

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Chilled Semen Shipment Information Form and Credit Card Authorization Form