Contact

BGLAD Veterinary Services
45 E 89TH Street # 31D
New York, NY 10128
Ph: 212-828-5663
Fax: 877-279-6288
Credit Card Authorization Form
Patient Name *
Client Name *
Age *
Breed *
Type of Card *

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Cardholder Name (as it appears on card): *
Upload the filled-out PDF - Link above this form. *

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Address *

Phone *
Alternate Phone
Email *
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Being the cardholder, by signing below I understand and agree to the terms set forth in this agreement, agree to pay, and specifically authorize Bglad Veterinary Services to charge my credit card for all services provided. Bglad Veterinary Services is further authorized to charge this account for any future services rendered. Cancellation policy: all appointments can be cancelled up to 24 hours prior to your appointment without incurring any fees. After that you will be charged a FULL FEE for a last-minute cancellation.
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Credit Card Authorization Form