One Time Credit Card Authorization 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*VisaMastercardAmerican ExpressDiscoverLast 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 agreeI 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.CAPTCHANameThis field is for validation purposes and should be left unchanged. Δ
