General Information & Consent Form

Account Information & Service Agreement
Thank you for choosing Turtle Valley Equine Hospital for your horse's care. This Agreement will govern the veterinary services we provide to you as the owner either directly or as approved by an authorized agent listed below.

Please fill out our client/patient registration form as completely as possible to ensure we can provide you and your horse with the best possible care.
Owner Information
Owner's Name*

First NameLast Name
E-mail*
Main Contact Number:*
What is the best number to reach you?
Secondary Contact Number:
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Referral Information
Referring Veterinarian/Practice (if applicable)
Phone Number (if known)
Authorized Agent Information
Is there someone you would like listed as an Authorized Agent on your account? By listing an authorized agent, I authorize this person to make medical decisions and consent to treatment for my horse(s) and give him/her permission to charge such appointments/medication to my payment source on file.
Yes, I wish to designate an authorized agent to act on my behalfNo, I do not wish to designate an authorized agent at this time
Name of Person to Be Authorized Agent

First NameLast Name
Phone Number of Authorized Agent

Patient Information
Horse's Name*
Breed*
Color*
Date of Birth/Age of Your Horse*
Sex/Gender*

MareStallionGelding
Is Your Horse Insured?*

YesNo
Insurance Company/Agent
Primary Reason for Appointment/Examination*
Select Appointment or Condition Type:*

Emergency Condition (Ex. colic, laceration, etc...)Scheduled Exam or ConsultScheduled Surgical AppointmentOther
Any Known Allergies, Vices, or other Pertinent History
You may upload any pertinent records, images, or files for your horse here (optional)

Browse Files
Please upload if available. Cancelof
Upload A Picture of Your Horse (optional)

Browse Files

Cancelof
Take Photo (smartphone or tablet users)

Policies and Procedures

We want you to be aware of and understand the following policies and procedures for all clients.
FINANCIAL POLICY:

Payment in full is required at the completion of services prior to discharge or release from the hospital. In order to secure your account with Turtle Valley Equine, a credit card on file and/or a security deposit is required for all emergency cases. Final payment may be made by any of the payment methods listed below.

Our office accepts Visa, Mastercard, Discover, and American Express. In addition, we also offer 3rd party financing options for our clients via Care Credit and Scratchpay. We accept a variety of Care Credit plans based on the total transaction amount for your pet. Care Credit requires that payment only be made for services as they are rendered, we cannot charge services to your account in advance. Additionally, use of Care Credit requires that the card be present every time and that two forms of identification are verified. We appreciate your understanding of our desire to protect your account/identity.

As financing options are offered, we cannot offer additional in-house payment plans for our services. Clients needing additional financial support are encouraged to apply for Care Credit with a co-signer.

Full payment is due at the time of service. This includes any charges/fees agreed to by any authorized agent. Our team is happy to provide any client with a written estimate prior to services being rendered. Clients will be responsible for a 1.5% monthly finance charge on accounts over 30 days and any collection and/or legal fees on accounts over 90 days. Your signature below indicates your agreement with these policies.

Patient Insurance: The insurance carrier for animals is handled differently than the medical insurance carried for yourself. Veterinary clinics are not reimbursed directly by the insurance companies for services rendered, rather they will only reimburse the policy holder. Turtle Valley Equine Hospital will assist in completing the required insurance paperwork for your reimbursement once the account has been paid in full. In rare instances there may be additional office charges for time required to complete extensive paperwork.
TREATMENT CONSENT:

By signing this document, I declare I am the lawful owner of all listed animals and all information is true and correct to the best of my knowledge. I hereby authorize the veterinarian(s) Turtle Valley Equine Hospital or their assistants to examine and/or perform the necessary procedures to the best of their abilities.

If any unforeseen condition arises during the course of the procedures which in their judgment call for additional to or different from those originally described every effort will be made to contact the owner/agent, however, if contact is not possible or can not be established in a timely manner I further authorize them to do whatever is necessary to avoid unnecessary suffering by the animal (including euthanasia in extreme cases). I authorize the use of appropriate sedation and/or other medication(s) and I understand that hospital support personnel will be utilized as deemed necessary by the veterinarian. I have been advised as to the nature of the procedure(s) or operation(s) and the risks involved. I acknowledge that no guarantee has been made as to the results that may be obtained.

I am the legal owner or representative of the legal owner of the animal being presented and I am over the age of 18 years.

I assume responsibility for all charges incurred in the care of this animal. I acknowledge that medical information will not be released to anyone not indicated on this form without my express verbal and/or written permission with the exception of another veterinary facility.
Signature*
Should be Empty:

Account Information & Service Agreement

Owner Information

Referral Information

Authorized Agent Information

Patient Information

Policies and Procedures