Card On File Authorization

Rogue Equine & Companion Animal Clinic accepts most major credit and debit cards. All personal information is kept private. You may cancel this authorization at any time by contacting us in writing. The authorization will remain in effect until cancelled.

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*
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
Signature*
User finger for tablets or phone, mouse if using a PC/Mac.
Date of Signing*
MM slash DD slash YYYY
Consent to record, retain authorization and process payment.*
I agree
I hereby authorize Rogue Equine & Companion Animal Clinic to process the above Credit Card as "Signature on File" for agreed upon veterinary services. I understand that this information will be securely saved on file for future transactions on my account.
If I request/require advance notification prior to processing, I agree to receive such notification by EMAIL in the format of an invoice or statement and will respond immediately if a discrepancy is discovered.
I agree that processing will take place and a 2.5% card charge fee will be added, within 2 business days, after an invoice or statement has been sent - by email. It is the receiver's responsibility to ensure email may be received from rveh.com or rogueequine.com domain.
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.
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Card On File Authorization

Card On File 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.