Credit/Debit Card Payment Authorization FormBy signing this form you give us permission to debit your debit/credit card for the amount indicated on or after the indicated date. This authorization form will remain on file for future services upon prior notification only. This form is for internal use onlyAccount Number* Customer Name* Card Type* Visa Master Card American Express Discover Card Number* Expiration Date* CVV2 Number* Name on Card* Billing Address for Card* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone Number*Pet's Name* Breed* Sex* Age* Color* Procedure* Amount* Date* MM slash DD slash YYYY Signature*By signing this form I authorize Westwood Veterinary Clinic to charge the card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit/debit card and that I will not dispute the payment with my credit/debit card company; as long as the transaction corresponds to the terms indicated in this form.CAPTCHANameThis field is for validation purposes and should be left unchanged.
