New Appointment Form

Owner & Appointment Info
Vet Info
Horse Info
Management Info
Horse Health info
Terms & Conditions

Vet Info

Who is your primary care veterinarian?

Primary Care Vet Email:

Primary Care Vet Phone Number:

Who referred you for this appointment?

Referring Vet Email:

Referring Vet Phone Number:

Farm Info

Farm Name

Farm Address

Address

City

State

Zip Code

Please add any directions or special instructions to get to the barn and/or location of your horse (i.e. directions, gate code, which barn, etc.).

Horse Info

Horse Name / Barn Name (Please include show name & barn name)

Breed

Sex

Color / Markings

Age or Birth Date

Weight (Approximate)

How long have you owned your horse?

Has your horse been vaccinated for Rabies within the last year?

Yes

Is your horse insured?

Yes

Will you be submitting a claim to your insurance company for this visit?

Yes

Since your horse is insured, please be sure to have your insurance company send the form to us at equineimed@gmail.com. Please note there is a one-time $25 fee for filling out insurance forms.

Diet:

What Feed is your horse currently on? (Note: Use the "+" Button to Add Another Feed Brand / Type)

Brand / Type	Amt AM	Amt PM

Hay & Forage (Type & Amount)

Is your horse turned out on pasture?

Yes

How many hours?

Is your horse on any supplements?

Yes

Supplements (Note: Use the "+" Button to Add Another Supplement)

Name	Amt AM	Amt PM

Is your horse currently on any medication(s)?

Yes

Please list ALL MEDICATIONS that your horse is currently on or has had in the last 30 days.

Name	Dosage	Frequency	Start Date	End Date	Still On?

Terms & Conditions

Please review and agree to the following terms & conditions prior.

Terms & Conditions

I understand that payment is required at the time of service unless other arrangements have been made prior to the appointment. If the horse is insured, payment will be made directly to Dr. Amy Polkes for the services performed and reimbursement will come from your insurance company.

I understand that I must pay my account in full within 30 days of the invoice. Invoicing is done through email and an accurate email address will be provided. Late charges shall be applied to all overdue accounts at the rate of 1.5% monthly. A $25 fee will be charged for declined credit cards.

I understand that the credit card on file will automatically be charged unless a check is provided the day of the visit, or alternate payment arrangements are made. Any time a charge is applied to your card, a paid invoice will be provided for your records.

Should Equine Imed have be required to commence administrative or legal action to collect an unpaid balance from you: 1) You agree to pay all costs, including reasonable attorney’s fees, incurred by Equine Imed associated with such action; 2) You represent that you are presently able to comply with the payment terms herein. If you should become unable to make timely payment of an outstanding balance, you will contact Equine Imed.

I hereby authorize Equine Imed to provide care to my horse(s) in my absence or at the request of my authorized agent. This contract shall apply to any and all veterinary services provided by Equine Imed to any and all horses on my behalf.

By signing below you acknowledge that you understand and accept all of these terms.

New Appointment Form

Owner Info

Payment

Appointment Info

Vet Info

Farm Info

Horse Info

Diet:

Horse Health Info

File Upload

Terms & Conditions