HomeResourcesFormsCredit Card Authorization Form Credit Card Authorization Form Cardholder InformationName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Patient InformationName* Species* Breed* Credit Card InformationCard Information Visa Mastercard Discover Care Credit Credit Card Number Expiration Date Card Identification Number (last 3 digits located on the back of the credit card)Amount DepartmentDepartment* Cardiology Internal Medicine Oncology Ophthalmology Rehabilitation Surgery 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.Cardholder Signature*Print Name* Date* MM slash DD slash YYYY CAPTCHA