New Appointment Form

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.

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

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.

Name

First NameLast Name

Signature

Consent Form

Terms and Conditions