New Appointment Form

Please note: This form should take approximately 20-30 minutes to fill out. This information is neccessary for a productive appointment, as Dr. Polkes reviews everything ahead of time and factors it into her examination. If is taking longer than 30 minutes, please hit save and continue at the bottom of the form. Thank you

Owner*

Owner email *

Owner phone*

Owner address*

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)?*

Name of main contact for appointment *

Phone Number*

Relationship (trainer, barn manager, family member...)*

Will you be attending the appointment?*

Name of person attending *

Phone Number*

Relationship to Owner*

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? *

Is the person attending the appointment the same person who should be sent the pre-appointment instructions?*

Name of person responsible for pre-appointment instructions*

Pnone*

Email*

Primary Care Veterinarian*

Primary Care Vet email

Primary Care Vet phone*

Did they refer you for this appointment?

Referring Veterinarian*

Referring Vet email

Referring Vet phone

Farm*

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

Horse's Barn Name*

Horse's Show Name

Breed*

Sex*

Age*

Weight (approximate)

How long have you owned this horse?*

Color of horse

Markings

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.

Please list all feed your horse is currently on*

Please list all feed your horse is currently on

	Brand/ Type	Amount AM	Amount PM
Feed
Feed
Feed
Feed

Do you need to add more feed?

Please list all feed your horse is currently on

	Brand/ Type	Amount AM	Amount PM
Feed
Feed
Feed
Feed

Do you need to add more feed?

Please list all feed your horse is currently on

	Brand/ Type	Amount AM	Amount PM
Feed
Feed
Feed
Feed

Do you need to add more feed?

Please list all feed your horse is currently on

	Brand/ Type	Amount AM	Amount PM
Feed
Feed
Feed
Feed

Hay and Forage

	Brand/ Type	Amount
Hay and Forage
Hay and Forage
Hay and Forage
Hay and Forage

Hay and Forage

Is your horse turned out on pasture*

How many hours?

Is your horse on any supplements?*

Please list all supplements that your horse is taking

	Brand	Amount	Frequency
Supplement
Supplement
Supplement
Supplement
Supplement

Do you need to add more supplements?

Please list all supplements that your horse is taking

	Brand	Amount	Frequency
Supplement
Supplement
Supplement
Supplement
Supplement

Do you need to add more supplements?

Please list all supplements that your horse is taking

	Brand	Amount	Frequency
Supplement
Supplement
Supplement
Supplement
Supplement

Do you need to add more supplements?

Please list all supplements that your horse is taking

	Brand	Amount	Frequency
Supplement
Supplement
Supplement
Supplement
Supplement

Please list all supplements your horse is taking

Has your horse been on any medication within the last 30 days?*

Please list all medications that your horse is taking

	Name	Dosage	Frequency	Start Date	End Date	Still On
Medication
Medication
Medication
Medication
Medication

Do you need to add more medications?

Please list all medications that your horse is taking

	Name	Dosage	Frequency	Start Date	End Date	Still On
Medication
Medication
Medication
Medication
Medication

Do you need to add more medications?

Please list all medications that your horse is taking

	Name	Dosage	Frequency	Start Date	End Date	Still On
Medication
Medication
Medication
Medication
Medication

Do you need to add more medications?

Please list all medications that your horse is taking

	Name	Dosage	Frequency	Start Date	End Date	Still On
Medication
Medication
Medication
Medication
Medication

Please list medications

What is the reason for this appointment?*

Please describe the concern with the horse that has led to this appointment

Has your horse had a gastroscopy within the last year?

Please email the prior gastroscopy findings to equineimed@gmail.com or upload results below

Has your horse ever been treated for gastric ulcers?

Please list medications tried for Gastric Ulcers

	Dosage	Frequency	Start Date	End Date	Still On
Medication
Medication
Medication
Medication

Do you need to add more Gastric Ulcer medications?

Please list medications tried for Gastric Ulcers

	Dosage	Frequency	Start Date	End Date	Still On
Medication
Medication
Medication
Medication

Do you need to add more Gastric Ulcer medications?

Please list medications tried for Gastric Ulcers

	Dosage	Frequency	Start Date	End Date	Still On
Medication
Medication
Medication
Medication

Please list medications given for gastric ulcers

Is the problem Acute (less than 6 weeks) or Chronic?

When did the problem start?

Date

Please list any medications that have been tried for this problem

When does the problem occur

At restDuring exerciseOther

Please describe when the problem occurs

Is the horse currently being ridden?

Any exercise intolerance?

Where does your horse reside?

Check all relevant symptoms

Nasal DischargeCoughingSneezingOther

Please describe symptom

If the problem is seasonal, please choose when it occurs

SummerFallWinterSpring

Has your horse had allergy testing?

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

Is strangles a concern at this time?

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?

Have any diagnostic tests been performed? (Radiographs, CT, EPM testing, other)

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

Has your horse been diagnosed with EPM?

Has your horse been treated for EPM?

Please list medications given for EPM

	Dosage	Frequency	Start Date	End Date	Still on
Medication
Medication
Medication
Medication

Do you need to add more EPM medications?

Please list medications given for EPM

	Dosage	Frequency	Start Date	End Date	Still on
Medication
Medication
Medication
Medication

Please list medications given for EPM

Has your horse had a prior Cardiac workup?

When?

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

Is the horse currently being ridden?

Any exercise intolerance?

Reason for not being ridden?

Type of riding/discipline?

Riding discipline

Please upload any health files that are relevant to your horse's health

Please confirm that you have uploaded any/all relevant health files for your appointment above.*

Yes, I have uploaded filesI do not have any health files to upload

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

YesNo

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.

Is your horse insured

Will you be submitting a claim for this visit?

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.

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

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.

Signature

New Appointment Form

Client Information

Vet Information

Appointment Location Information

Horse Information

Horse Management Information

Horse Health

File Upload

Terms and Conditions