REQUEST FOR CREDIT CARD AUTHORIZATION

Instructions to Rescue Representative: Please send this form at least 3 days prior to the vet visit. Include all information. If the fax isn’t sending, I need to be able to call the vet, and I need time to do this.

Dog's Name(s): Date of Visit: 
Services Needed: Expected Cost:
Veterinarian Name: Clinic Name:
Clinic Phone #: Clinic Fax #:
Rescue Rep Name: Rescue Rep Phone:
Rescue Rep email: Additional Notes:

Questions? Send me an email. - Zofia