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Credit Card Authorization Form

Save time during your next appointment! Complete your credit card authorization form online from any device at any time before your visit.

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Online Forms

Credit Card Authorization Form

If this is your first visit to Laurel Pet Hospital and would like a faster and easier check-in on your arrival, please fill out the form below.

If you have an emergency or do not have the means to complete the form in advance, don’t worry; one of our helpful receptionists will provide them to you when you arrive.

Pet Owner’s Name: *

First

Last

Card Holder Name: *

First

Last

Card Number: *

Expiration Date: *

CVV Code: *

Card Type: *

Billing Address: *

Address Line 1

Address Line 2

City

State

Zip Code

PLEASE INITIAL ONE:

I Authorize Laurel Pet Hospital to charge my credit / debit card for veterinary services.

(one time use only)

I Authorize Laurel Pet Hospital to keep my card number on file for future use.

AUTHORIZATION FOR PAYMENT OF MEDICAL TREATMENT

I assume financial responsibility for all charges incurred to the patient and consent to the reals of medical information to the above name family veterinarian. I understand the clinic and its personnel does not give any guarantee that the recommended treatments/procedures will correct or cure the conditions for which my pet was presented. I understand that if my credit or debit card is returned unpaid for any reason that will be subject to additional charges and that if a collection agency/attorney must be used to collect the balance of the charges resulting from care received by my pet at Laurel Pet Hospital, I will be responsible for paying any collection cost/fees.

Date *

Phone

Credit Card Authorization Form

Online Forms

Credit Card Authorization Form

PLEASE INITIAL ONE:

AUTHORIZATION FOR PAYMENT OF MEDICAL TREATMENT

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