• Credit/Debit Card Payment Authorization Form

    By 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 only
  • Date Format: MM slash DD slash YYYY
  • 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.
  • This field is for validation purposes and should be left unchanged.