Credit Card Authorization Form

Southwest Veterinary Surgical Service, PC

Credit Card Authorization Form

By submitting this form, you acknowledge that the information provided may be used by Southwest Veterinary Surgical Service for patient care, client communications, billing, referral management, and related administrative purposes. Contact us directly if immediate assistance is needed.

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 *

Phone

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By Appointment

Southwest Veterinary Surgical Service, PC

Credit Card Authorization Form

GILBERT

PEORIA

SCOTTSDALE

TUCSON