Card Hold Authorization

Rogue Equine & Companion Animal Clinic accepts most major credit and debit cards. All personal information is kept private. This hold authorization may transition to an actual credit card charge under circumstances listed in this form. The authorization will remain in effect until cancelled by us, or by natural expiration under the terms of your credit card provider.

Cardholder Name ( as it appears on card)*
First Middle Last
Card Type - Choose One*
Last 4 digits*
Please only list the last four digits of your card. This is for confirmation purpose - that we are using the correct card.
Expiration Date: Month/Year (MM/YY)
This field is hidden when viewing the form
Expiration Date*
MM slash DD slash YYYY
Billing Address and ZIP Code for the card listed. This must match the card placed on file.*
ZIP Code
Name of Person Signing*
First Middle Last
Amount to be held or placed on hold.*
You will be advised on the amount to enter and will be held for potential use as noted and agreed upon below. Please read and ask if you have any questions.
Consent to record, retain authorization and process payment.*
I agree
I hereby authorize Rogue Equine & Companion Animal Clinic to place a Credit Card Hold amount as noted on this form, as a method of secure payment for agreed upon veterinary services. Secure means a locked or held state for potential processing under the following circumstances: 1) Verbal agreement by the card holder to convert the held amount to an actual credit card transaction to satisfy a balance due for services rendered, 2) Failure to present payment as agreed following completion of a procedure or treatment, or 3) Failure to present payment at the time of delivery of care back to owner or person responsible or 4) Upon discovery by employees of Rogue Equine and Companion Animal of Insufficient funds (NSF Check) on a check written to Rogue Equine and Companion Animal Clinic.
Authorization of a "Hold" means the amount noted on this form will be locked in and not available to the card holder for any other transaction. Though the transaction is not fully processed as a card transaction, the potential exists due to any event as listed above. In essence, you are agreeing in advance to the conversion of the held amount to a bonafide transaction due to reasons above.
Please note, a hold may remain for an unspecified time due to the terms of the card holder's provider. Where possible, the hold will be removed by Rogue Equine and Companion Animal when all terms have been satisfied or other means of payment have been received. Note that customers bank may control and extend the period by which a "hold" is in effect, which is out of the control of Rogue Equine and Companion Animal Clinic, or Rogue Equine.
Furthermore, a 3.0% card charge fee may be added to the invoice total if the hold is processed as a transaction.
In the event a customer refuses conversion of a "held" amount, or the executed "hold" conversion to a transaction, the provided invoice amount is due and payable "on receipt", which means by next business day. If payment is not received under the terms stated above, the invoice due amount plus a $26.00 fee is transferred to a third party billing service for processing. This fee is a pass-through cost charged by the third party billing entity. This is in addition to interest applied (2.0%) to balances due over 30 days.
Upon signing this form, the card holder expressly agrees to all terms preceded by this statement.
Signature*
User finger for tablets or phone, mouse if using a PC/Mac.
This field is hidden when viewing the form
Date of Signing*
MM slash DD slash YYYY
Please note - the next page will contain a link to store your card securely. Failure to complete this second step will interfere with our ability to provide service. If we already have your card on file, you may ignore the instructions on the next page.

for compassionate, personalized, expert veterinary medical care
serving Southern Oregon and Northern California.

Card Hold Authorization

Please note - the next page will contain a link to store your card securely. Failure to complete this second step will interfere with our ability to provide service. If we already have your card on file, you may ignore the instructions on the next page.

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