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Home
About Us
Veterinarians & Staff
Service Area
Testimonials
Payment Options
Online Bill Pay
Services
Premier Services
Emergency Care
Horse Vaccines
Equine Dentistry
Resources
Lectures
Online Forms
Farrier List
Small Animal Emergency Clinics
Additional Resources
News
Contact
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
Cell Phone
Work Phone
Email
*
Place of Employment
*
Horse #1 Information
Horse's Barn Name
Horse's Registered Name
*
Breed
*
Gender
*
Male
Female
Date of Birth
*
Date Format: MM slash DD slash YYYY
Stable
Phone
Authorized Agent(s)
*
First
Last
Phone
Would you like to add another horse?
Yes
No
Horse #2 Information
Horse's Barn Name
Horse's Registered Name
*
Breed
*
Gender
*
Male
Female
Date of Birth
*
Date Format: MM slash DD slash YYYY
Stable
Phone
Authorized Agent(s)
*
First
Last
Phone
Would you like to add another horse?
Yes
No
Horse #3 Information
Horse's Barn Name
Horse's Registered Name
*
Breed
*
Gender
*
Male
Female
Date of Birth
*
Date Format: MM slash DD slash YYYY
Stable
Phone
Authorized Agent(s)
*
First
Last
Phone
Would you like to add another horse?
Yes
No
Horse #4 Information
Horse's Barn Name
Horse's Registered Name
*
Breed
*
Gender
*
Male
Female
Date of Birth
*
Date Format: MM slash DD slash YYYY
Stable
Phone
Authorized Agent(s)
*
First
Last
Phone
I authorize my agent to make appointments and order medication for my horse(s) 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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Comments
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