Credit Card Authorization Form

Southwest Veterinary Surgical Service, PC

Credit Card Authorization Form

Select the Southwest Veterinary Surgical Service location where payment will be processed *

Gilbert
Peoria
Scottsdale
Tucson

Patient Name associated with Southwest Veterinary Surgical Service *

First

Last

This is the full name of the pet we are caring for

*Credit Card Billing Address *

*Billing address must include street, city, state, and zip and must match the billing address on file with the credit card being used.

City *

State *

Zip Code *

Client's Primary Phone Number *

Client's Secondary Phone Number

Date(s) of Service *

Amount Authorized *

Card Number *

Expiration Date *

**Card Security Code *

**Visa, Mastercard, and Discover have a 3 digit code on the back of the card (above the authorized signature area). American Express has a 4 digit code on the front of the card.

Card Holder's Name *

First

Last

Type of Card *

Visa
Mastercard
Discover
AMEX

Driver's License Number *

State Issued *

Expiration *

Authorization *

I authorize Southwest Veterinary Surgical Service, PC to charge my credit card for veterinary services provided for my pet. I understand that I am giving the above named practices(s) permission to charge my credit card without my signature on the charge slip.

Card Holder Signature *

First

Last

Today's Date *

Comment

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Southwest Veterinary Surgical Service, PC

Credit Card Authorization Form

GILBERT

PEORIA

SCOTTSDALE

TUCSON