VetMED Veterinary Hospital

202 N. Walnut St.
Bay City, MI 48706


Credit Card Authorization Form

We require a third- party payee to fill out the Credit Card Authorization Form to verify that the person who is covering the bill is allowing us to use their information. If you prefer not to fill the form out online please contact us so we can provide a different avenue for you to fill out this form.

Credit Card Authorization Form

Date (required) :
Name (required)
First Name (required)
Last Name (required)
Address (to mail receipt, if requested)
Street Address
State / Province
Zip / Postal Code
E-Mail Address (required) :
Credit Card Number (required)

Expiration Date (required) :
Cardholder's Name (as it appears on the card): (required)

Credit Card Type (required) :
Must provide a valid picture I.D. Send Via (required)

Email to
Fax to 989-686-1761
In Person

I agree to pay the amount for services for (Pet's Name), owned by (Client's First and Last Name) (required)

I have filled out this form with accurate information (required)


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