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  • New Appointment Form

  • Please note: This information is neccessary for a productive appointment, as Dr. Polkes reviews everything ahead of time and factors it into her examination. You can save your progress by selecting save and continue at the bottom of the form. 

  • Client Information

  •  -
  • Are you over the age of 18?*

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

  • Are you the main contact for this appointment (scheduling and arrival day of appointment)?*
  •  -
  • Will you be attending the appointment?*
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  • Does the person attending appointment have the ability to authorize recommended diagnostics?*
  • If treatment is recommended, does this person have authorization to accept medication on your behalf?*
  • Format: (000) 000-0000.

  • Vet Information

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  • Did they refer you for this appointment?*
  •  -

  • Appointment Location Information

  • Horse Information

  • Is the horse in work?*
  • Has your horse been vaccinated for Rabies within the last year?*

  • Your horse's Rabies vaccination must be up to date to make an appointment. 

  • Horse Management Information

  • Diet, supplements and medication are all taken into consideration when assessing your horse. It is important that this information be included and accurate.

  • Is your horse turned out on pasture*
  • Is your horse on any supplements?*
  • Has your horse been on any medication within the last 30 days?*

  • Horse Health

  • Has Dr. Polkes seen this horse before?*
  • Has it been over 90 days since the last appointment*
  • Has your horse had a gastroscopy within the last year?*
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  • Has your horse ever been treated for gastric ulcers?*
  • Is your horse on a regular deworming program*
  • Is the problem Acute (less than 6 weeks) or Chronic?
  • When did the problem start?
     - -
  • When does the problem occur
  • Check all relevant symptoms
  • If the problem is seasonal, please choose when it occurs

  • Please email test results to equineimed@gmail.com or upload results below

  • Please contact us to schedule an appointment, it must be arranged for end of day due to the contagious nature of Strangles

  • When did the problem start?
     - -

  • Please email test results to equineimed@gmail.com or upload results below

  • When?
     - -

  • Please email cardiac evaluation results to equineimed@gmail.com or upload results below

  • File Upload

  • Please confirm if you have uploaded any/all relevant health files for your appointment below.*
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  • Terms and Conditions

  • Is the owner listed the person financially responsible for the bill?*

  • The person financially responsible must contact the office to make payment arrangements prior to scheduling the appointment. Please note this appointment will not be confirmed without payment arrangements in advance of the appointment.

  • Are you submitting the appointment through insurance?*

  • Please have your insurance company send the form to stacys@equineimed.com. There is a one-time $25 fee for filling out insurance forms.

  • Please note: We must have a form of payment on file in order to schedule this appointment. Please contact at Stacy 845-444-0134 to provide this information. 

  • Please review and agree to the following terms and conditions prior to submitting*
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