Admittance Form – The Pet Doctor of Flushing

Your Full Name *

Patient's Name *

Phone Number *

Reason patient is coming in for *

Credit Card Authorization Form

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

Credit Card *

Credit Card

Credit card Number

Card expire month

Card expire year

Cardholder ZIP code (from credit card billing address)

Credit card Type *

Enter credit card type *

By click on below checkbox I, authorize Pet Doctor Clinic to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.
06/13/2021

Accept Terms *

Accept above terms and conditions

Signature *

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