CREDIT CARD AUTHORIZATION FORM Our Vision is Caring For Your Pet's Vision Form Submission is restrictedForm is successfully submitted. Thank you!Credit Card Authorization FormInstructions: If you wish to pay us by credit card or care credit, please complete this form and return to us, together with a copy of your driver’s license.Do you have an appointment scheduled at one of our MAIN locations?CalabasasAlhambraOR is your appointment scheduled at one of our SATELLITE clinics?VenturaRancho CucamongaCARD TYPE:*VISAMasterCardAmerican ExpressDiscoverCredit or Debit Card Holder’s Name:*Billing Address:*City*State*Zip Code*Phone NumberFax NumberClient’s Email Address:*NAME OF ISSUING BANK/CREDIT CARD NAME:*CREDIT CARD NUMBER:*Expiration Month*Please SelectPlease selectJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberExpiration Year*Please SelectPlease select2020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050CVC*Upload photo of your Driver’s License Upload% Completed0By signing below, the above named cardholder hereby authorizes Veterinary Eye Clinic Inc. to verify the cardholders identity and charge $*to the credit card identified above as payment towards the treatment and procedure performed to*CARDHOLDER’S AUTHORIZATION SIGNATURE:*Date:* Submit
