New Appointment Form

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.

Name

First NameLast Name

Signature

Consent Form

Terms and Conditions