Four Star Equine Veterinary Services Agreement

Fillable Form

Owner

First Name

Last Name

Co-owner

First Name

Last Name

Primary phone

(###)

###

####

Secondary phone

(###)

###

####

Mailing Adress

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please list all horses currently in your ownership

Include registered name/barn name, gender (mare/gelding/stallion) and age/DOB

Location of horses (if other than your home address), include physical address

Authorized agent(s)

List agent(s) authorized to order veterinary care in your absence. Your horse’s medical information will be shared/discussed with your authorized agent if they are acting in your absence. You agree to furnish payment for all goods and services rendered to your horse(s) at the request of your authorized agent(s). You may add or remove agents from this list by written request (email or letter) to Four Star Equine. Please include first and last name, relationship, and phone number for each agent.

I authorize the above listed agent(s) to make appointments and order medications for my horses and will be financially responsible for all charges incurred at my agents request for my horse(s)

In the event that I am absent and cannot be reached, and my horse is experiencing a life threatening condition:

If referral is indicated, I authorize my horse to be hospitalized

I do not authorize hospitalization in my absence. I understand that this may mean the treating DVM may humanely euthanize my horse if indicated. All reasonable attempts to contact you will be made first.

If you chose that you would like your horse hospitalized if indicated in your absence please list your preferred referral equine hospital below:

Also if you chose to authorize hospitalization you have made transportation arrangements with:

**Please note that this is necessary if you plan for your horse to be hospitalized in your absence. We do not provide transport services nor do have the ability to arrange emergency transport services in your absence.

Emergency Services

After hours emergency services are provided as a concierge service for our current clients in good standing. We reserve the right to refuse emergency services if you have an account balance aged more than 30 days that we have made reasonable attempts to collect. Emergency services are provided to horses for whom we have provided non-emergency elective wellness services to within the previous 15 months. Elective wellness services are defined as: wellness/physical exam, vaccinations, dental floats, sports medicine services, veterinary medical manipulation, and acupuncture treatments. A coggins test, fecal float or health certificate alone does not qualify your horse(s) for emergency care.

I have read and agree to the Four Star Equine after hours emergency policy.

Communication Policy

We’re here to help! To best address your requests and concerns, we ask that all communication regarding scheduling, requests for medications, updates on your horse’s health and status, and questions regarding your horses care should be made by calling our office at (540) 481-0639 or 833-478-2737. Please do not utilize text messaging, social media messaging or email for these purposes unless it is requested or initiated by a staff member of Four Star Equine PLLC. We prefer text messaging be sent to 833-478-2737 as our support staff and DVMs can access text messages to this number. Our doctors and staff are available for non-emergency communication Monday-Friday 8am-5pm. Texts, emails and general voicemails are not monitored or returned outside of business hours. If you have an emergency or truly urgent concern outside of normal business hours please call (540) 481-0639 extension #6 to reach the doctor on call. Our practice utilizes email for document transfer only. Please do not send questions or scheduling requests via email.

I have read and agree to the Four Star Equine communication policy.

Financial Policy

We accept cash, check, credit and Care Credit as payment. Any account unpaid by 30 days will be subject to finance charges at an interest rate of 1.5% monthly (18% APR ) or the minimum monthly finance charge of $15, whichever is greater. Any account unpaid 90 days after date of invoice will be submitted for judgment of debt and/or collections. All reasonable collection and legal fees required to obtain payment for services will be charged to the client. A $50 fee will be applied for each returned check. Until payment is made in full, I hereby grant Four Star Equine PLLC a lien and security interest in the horse(s) for who services or goods are rendered. We strive to keep veterinary care affordable and can only do so if you as the client keep your account current and paid in full. If you have an unpaid balance on your account, no further elective or emergency services or goods will be provided to you until your account is made current.

I have read and agree to the Four Star Equine financial policy.

Credit Card on file

Must be provided if your horse is not kept at your physical residence, is under the care of a boarding or training facility, or if you cannot be physically present for every appointment and/or emergency.

You will be provided with updates to this policy as necessary.

By entering my full name below I acknowledge that I have read and understand the terms of the Agreement and Financial Policy and agree to the terms set forth

Date

YYYY

Click links below to open forms in a new window. Completed forms can be submitted by post to 9644 S Congress St. New Market, VA 22844 or email to fourstarequine@gmail.com