One Time Card Transaction Authorization - Rogue Equine & Companion Animal Clinic

One time authorization for credit card payment/charge for veterinary services provided by Rogue Equine & Companion Animal Clinic.

Cardholder Name ( as it appears on card)*
First Middle Last
Card Type*
Last 4 digits*
Expiration Date*
MM slash DD slash YYYY
Billing Address ZIP Code*
ZIP Code
Name of Person Signing*
First Middle Last
Authorized Dollar Amount*
Please enter the amount provided to you or agreed upon. If the amount is different, we will notify you as the transaction will be rejected.
Signature of Person Signing*
User finger for tablets or phone, mouse if using a PC/Mac.
Date of Signing*
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 ONE TIME agreed upon veterinary services. I understand that this information will NOT be saved for future transactions.
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Email
This field is for validation purposes and should be left unchanged.

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