Third-Party Credit Card Payment Authorization

Third-Party Credit Card Payment Authorization

Fields marked with an * are required.
By signing below, you are authorizing Animal Emergency Hospital DeLand to process your credit card payment remotely for the care of your pet. Please be advised we DO NOT accept American Express as a payment method. Once your authorization has been submitted, you will receive a call from 386-252-0337, and a staff member will process your payment over the phone.
Card Holder's Name*

First NameLast Name
Card Holder's Email*
example@example.com
Client Phone Number*
Example 555-555-5555
Pet's Name*
Credit Card Type*
Debit, Credit, etc.
Last 4 Digits of Credit Card Number*
Purchase Amount*
Date*

MonthDayYear
Card Holder's Signature*

Clear
Please upload an image of your identification:*

Driver's License, State ID, etc.
Cancelof
Should be Empty: