Form - Veterinary Services Agreement -

All new clients must pay for their first appointment by cash or credit card. Payment is required a the time of service.

Horse Owner Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Work Phone

Email*

Place of Employment*

Horse Information

Horse's Barn Name

Horse's Registered Name*

Breed*

Gender*

Male
Female

Date of Birth*

Stable

Phone

Authorized Agent(s)*

First Last

Phone

I authorize my agent to make appointments and order medication for my horse and give him/her permission to charge such appointments/medications to my credit card.*

Yes
No

I authorize the release of medical information about my horse(s) to my agent.*

Yes
No

Account Information

(Required - please initial after each statement)

I understand that I must pay all accounts in full upon receipt of invoice.*

I understand.

I would like to sign up for EZ pay to have my bills automatically charged to the credit card I have on file. Any time a charge is applied to your card, we will send you an invoice for your records.*

Yes
No

I hereby authorize Premier Equine Veterinary Service to provide routine and emergency care to my horse(s) whether or not the horse is listed above in my absence or at the request of my barn management/trainer/authorized agent.*

I authorize.

You represent that you are presently able to comply with terms herein, and that if you should become unable to make timely payment of outstanding invoices, you will notify Premier Equine Veterinary Service.*

I agree.

All accounts that remain unpaid after 60 days are considered past due. A late fee of 2% per month. Client shall pay all costs and expenses, including reasonable attorney's fees, which are incurred by Premier Equine Veterinary Service to collect any past due accounts.*

I agree.

Credit Card #

Exp. Date

CVV

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Name

This field is for validation purposes and should be left unchanged.

Veterinary Services Agreement

Horse Owner Information

Horse Information

Account Information

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