Telehealth Intake Form

Telehealth Form

Owner Info
Horse Info
Horse Health Info
Payment

Owner Info

Owner First Name

Owner Last Name

Owner Address

Address

City

State

Zip Code

Owner Email Address

Owner Phone/Mobile

Who is your primary care veterinarian?

Who referred you for this appointment?

Which veterinarian would you like us to share the records with?

Horse Info

Horse Name

Sex

Age or Birth Date

Breed

Weight

Color / Markings

How long have you owned your horse?

Horse Health Info

What is the reason for today's requested appointment?

When did the problem start?

Feed (Note: Use the "+" button to add another feed brand / type)

Type / Brand	Amount AM	Amount PM

Supplements Feed (Note: Use the "+" button to add another supplement)

Type / Brand	Amount AM	Amount PM

Is your horse currently on any medication(s)?

Yes

Medications (Note: Use the "+" button to add another medication)

Name	Dosage	Frequency	Start Date	End Date

File Upload

Please upload any health files that are relevant to your horses appointment.

Relevant Health Files

Choose File

Pay & Submit

Is your horse insured?

Yes

Since your horse is insured, please be sure to have your insurance company send the form to Dr. Polkes at dramypolkes@gmail.com. We do not recommend sending the medical record notes to the insurance company as the insurance form asks specific questions that Dr. Polkes needs to answer pertaining to the claim.

Please note there is a one-time $20 fee for filling out insurance forms.

Is the owner listed above the person financially responsible for the bill ?

Yes

If the owner is not financially responsible for the bill, who will be paying?

What is the best phone number to reach them?

Please note that this appointment cannot be confirmed without payment arrangements in advance of the appointment.

I acknowledge that the credit card on file will be charged after the visit. If I need to make a change in payment, I will promptly contact Marilyn at 845-444-0134 in advance of the appointment.