Recheck Appointment Form

Owner

Horse Barn Name

Horse Show Name

Has the appointment location changed?

Appointment address

Are there any specific instructions or directions ?

Are there any changes to your contact information since the last appointment?

Owner phone

Owner email

Owner address

Are there any changes to your Primary Care Veterinarian since the last appointment?

Primary Care Veterinarian

Primary Care Veterinarian phone

Primary Care Veterinarian email

Will you be attending the appointment?

Name of person attending

Relationship to Owner

Phone Number

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 preparation instructions?

Name of person who should be sent the pre-appointment preparation instructions

Email

Phone Number

Format: (000) 000-0000.

Type of Recheck

Have you completed any of the medication as prescribed?

Please list medications and date completed

Rows	NAME OF MEDICATION	DATE COMPLETED
MEDICATION
MEDICATION
MEDICATION
MEDICATION
MEDICATION
MEDICATION

Is your horse still taking any of the prescribed medication?

Please fill out medications still taking and the date started

Rows	NAME OF MEDICATION	DATE STARTED
MEDICATION
MEDICATION
MEDICATION
MEDICATION
MEDICATION
MEDICATION

Are there any prescribed treatments that have not been started?

Please fill out medications not started

Rows	NAME OF MEDICATION
MEDICATION
MEDICATION
MEDICATION
MEDICATION
MEDICATION
MEDICATION

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

If there have been any changes to your horse's diet and/or supplements, this is important information needed for your recheck examination

Please list all changes to diet or supplements

Is the horse currently in work?

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

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

Please contact the office with payment information prior to the appointment

Policy Acknowledgements

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.

Recheck Appointment Form

Client Information

Recheck

Payment