New Appointment Form

Owner Info
Horse Info
Horse Health Info
Payment
Terms & Conditions

Owner Info

Owner First Name

Owner Last Name

Owner Address

Address

City

State

Zip Code

Is the BARN ADDRESS the same as the owner's home address?

Yes

Farm Name

Barn Address

Address

City

State

Zip Code

Please add any directions or special instructions to get to the barn and/or location of your horse.

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?

Will you be at the appointment?

Yes

Appointment Attendee First Name

Appointment Attendee Last Name

Relationship to Owner

Appointment Attendee Phone/Mobile

Does the person handling the horse for the appointment have the ability to authorize recommended diagnostics?

Yes

If treatment is recommended, does this person have authorization to accept medication on your behalf?

Yes

Horse Info

Horse Name / Barn 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 the appointment?

What is the concern with your horse that is leading to this appointment?

When did the problem start?

Check all relevant symptoms :

Nasal Discharge

Coughing

Sneezing

Other

Has your horse been treated for or diagnosed with EPM?

Yes

Please upload any testing results

Choose File

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

Yes

When does the problem occur?

At Rest

Only During Exercise

Is the problem seasonal?

Yes

During what season (s)?

Does your horse have a history of strangles?

Yes

Is strangles a concern at this time?

Yes

Has your horse ever been diagnosed with ulcers?

Yes

If your horse has had a gastroscopy within the last year please upload relevant records.

Choose File

Is the deworming schedule through your veterinarian?

Yes

When was the last deworming and what product?

When was the last deworming?

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

Brand / Type	Amt AM	Amt PM

Does your horse get hay?

Yes

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?

File Upload

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

Relevant Health Files

Choose File

Payment

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. 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 $25 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.

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.

Color Picker