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About
Services
Client Forms
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Links
Contact
Veterinary Service Agreement &
Payment Policy
Name
*
First Name
Last Name
Contact phone number
*
(###)
###
####
Contact phone is:
Cell phone
Home phone
Work phone
Alternate phone number
(###)
###
####
Alternate phone is:
Home phone
Cell phone
Work phone
Billing address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
I prefer to be contacted by:
Phone call
Text
Email
I (the horse owner) authorize the following agent(s) to make health care decisions for my horse as detnoted below:
Trainer
Barn manager/owner
Family member/friend
Named agents are authorized to make the following decisions for my horse in my absence:
Emergency health care decisions
Routine health care decisions (Vaccination/Deworming)
All health care decisions
List authorized agents name, title, and contact phone number
Horse's Registered/Show Name
Horse's Barn Name
Color
Breed
Year of Birth
Gender
Gelding
Mare
Stallion
Name and address of stable where horse is located
Microchipped?
Yes
No
Microchip number:
Is horse insured?
Yes
No
If yes, through what insurance company?
If you were referred to us by a friend who can we thank for this referral?
Date of last negative Coggins test
MM
DD
YYYY
Date of last Rabies vaccine
MM
DD
YYYY
Date of last dental float
MM
DD
YYYY
Total number of horses owned (Please complete "Additional horse(s) form" if needed
Authorization to treat (Please check each statment to indicate your agreement)
*
I hereby authorize Commonwealth Equine to provide veterinary care to my horse(s) at my request as well as in my absence at the request of my authorized agent.
I consent to be financially responsible for all costs associated with veterinary care, services, and medications provided to my horse(s) by Commonwealth Equine.
This contract shall apply to any and all horses owned, leased, or under the care of the undersigned, whether or not the horse(s) are listed on this form.
I understand that payment is required at time of service or (with prior consent) within 10 days of services rendered.
The client can terminate this agreement at any time upon providing notice and will still be required to pay outstanding balance.
Thank you for choosing Commonwealth Equine! We appreciate your business! Our payment policy is designed to keep our billing process straightforward and our fees as low as possible. We request that payment for veterinary services provided be made at time of service unless other arrangements have been made prior to the appointment. We request that a current credit card be placed on file with our office. Your credit card will not be charged if payment is made at time of service. If payment is not made at time of service and no other arrangements have been agreed upon then your credit card will be charged within 5 days of services rendered. If payment is not made or if your credit card is declined and the matter is placed with an attorney for collection you will be responsible for all costs of collection including court fees, attorney fees, and interest on the unpaid balance from the date of services. Insurance claim payments for a major medical claim will be paid to you directly from your insurance company. Preferred method of payment at time of service:
*
Cash
Check
Visa/MasterCard on file
Acknowledgement of payment policy: If payment is not made at the time of service I understand that signals my consent to have my account settled in full by charging the balance to my credit card within 5 days of services rendered, unless prior arrangements have been agreed upon. Please check box to indicate your consent. Commonwealth Equine will contact you to securely acquire credit card payment information after this form is submitted.
*
I agree to uphold the above described payment policy.
Thank you for your interest! Commonwealth Equine will be in touch shortly to set up your account.
