Recheck Form - Equine Internal Medicine and Diagnostic Services

Owner Info

Owner First Name

Owner Last Name

Owner Address

Address

City

State

Zip Code

Owner Email Address

Owner Phone/Mobile

Are you over the age of 18?

Yes

You must be over 18 years old to book an appointment.

Will you be attending the appointment?

Yes

Appointment Attendee Name

Appointment Attendee Relationship

Phone/Mobile

If treatment is recommended, do they have authorization to accept medication?

Yes

Payment information

Would you like to pay with the credit card on file?

Yes

If no - please contact the office with payment information prior to the appointment

Vet Information

Name of Primary Care Veterinarian

Name of Referring Veterinarian

Farm Info

Farm Name

Barn Address

Address

City

State

Zip Code

Special Instructions (directions, gate code, which barn):

Horse Info

Horse Name

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)

Type / Brand	Amt AM	Amt PM

Hay & Forage (Type & Amount):

Is your horse on any Supplements?

Yes

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

Name	Amt AM	Amt PM

Is your horse still on the prescribed treatment protocol from your prior appointment?

Yes

Did you complete the prescribed protocol from your prior appointment?

Please explain.

Is your horse currently on medication(s) at this time?

Yes

Medications: Please list ALL MEDICATIONS that your horse is currently on or has had in the last 30 days. (Note: Use the "+" Button to Add Another Medication)

Name	Dosage	Frequency	Start Date	End Date	Still On?

Horse Health Info

Are there any specific concerns you would like addressed at this appointment?

Is your horse currently being ridden?

Yes

Type of Riding/Discipline

Reason?

Any concerns with exercise intolerance?

Yes

Is your horse turned out on pasture?

Yes

If so how many hours?

File Upload

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

Relevant Health Files

Choose File

Terms & Conditions

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

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 the office at 845-444-0134 in advance of the appointment.