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*
Date Format: MM slash DD slash YYYY
Billing Address ZIP Code*
ZIP Code
Name of Person Signing*
First Middle Last
Signature of Person Signing*
User finger for tablets or phone, mouse if using a PC/Mac.
Date of Signing*
Date Format: MM slash DD slash YYYY
Consent to record and retain authorization.*
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 saved on file for future transactions on my account.
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