Recheck Appointment Form

Owner*

If there are any changes to your contact information since the last appointment, please update below

Owner phone

Owner email

Owner address

If there are any changes to your Primary Care Veterinarian since the last appointment, please update below

Primary Care Veterinarian

Primary Care Veterinarian phone

Primary Care Veterinarian email

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?

Did you complete the prescribed treatment?

CompletedStill on

Date Completed

Please list any medications if currently taking

	Name	Dosage	Frequency	End Date
Medication
Medication
Medication
Medication
Medication

Are there any changes to the diet or supplements since the last appointment?

NoYes

Please list all changes to diet or supplements

Are there any concerns you would like to discuss at this appointment?

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

YesNo

Please contact the office with payment information prior to the appointment

Policy Acknowledgements

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.

Recheck Appointment Form

Client Information

Payment