• Cardholder Information

  • Patient Information

  • Credit Card Information

  • (last 3 digits located on the back of the credit card)
  • Department

  • I authorize Las Vegas Veterinary Specialty Center to charge the agreed amount listed above to my credit card provided herein. I understand that the above amount will be posted to the aforementioned credit card upon receipt of this authorization. Any additional charges/amounts must be approved by me and only me prior to the posting of said charges.

    In addition to this written authorization letter, a legible copy of my credit card both front and back and my state driver’s license must be attached, transmitted via facsimile with this authorization to 702-262-7000, or emailed to forms@lvvsc.com.

  • Date Format: MM slash DD slash YYYY