Credit Card Authorization Form

By signing this, I confirm I am an authorized cardholder, and consent to the manual entry of charges on to the card by Wellesley Animal Hospital in order to process payment for any charges incurred. I acknowledge the total amount may vary depending on the services/items provided, and a receipt will be issued for any and all charges made to the card. I further understand if an attempt to process payment manually is declined, I am still responsible for the balance owing, and payment must be remitted to Wellesley Animal Hospital within seven (7) days from the date the charges were incurred. *