One Time Card Transaction CEM Mare - Rogue Equine & Companion Animal Clinic

One time authorization for credit card payment/charge for CEM services provided by Rogue Equine CEM.

Cardholder Name ( as it appears on card)*
First Middle Last
Card Type*
Last 4 digits*
Expiration Date*
Date Format: MM slash DD slash YYYY
Billing Address ZIP Code*
ZIP Code
Name of Person Signing*
First Middle Last
Consent to record and retain authorization.*
I agree
I hereby authorize Rogue Equine CEM to process the above Credit Card as "Signature on File" for ONE TIME CEM services in the amount of $2523.50 ($2450.00 plus card transaction fee of $73.50). I understand that this information will NOT be saved for future transactions.
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
Your card is not processed until completion of the next step. Immediately after submission of your form you will see a confirmation page with a link to our secure card processing site. Please enter the amount of $2523.50 and your card details. Thank you!
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

Save and Continue Later