Credit Card Authorization Form in Las Vegas, NV - Las Vegas Veterinary Specialty Center

Cardholder Information
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Patient Information
Name*
Species*
Breed*
Credit Card Information
Card 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
Department
Department*
- 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

Cardholder Information