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Southwest Veterinary Surgical Service, PC

Credit Card Authorization Form

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

Patient Name associated with Southwest Veterinary Surgical Service

*Credit Card Billing Address:

Type of Card: VisaMastercardDiscoverAMEX

Drivers License:

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.

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

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