New Client Form

Client Name
MM slash DD slash YYYY
Address
Please Choose One:(Required)
Financial Policy Essex Equine, Inc. is dedicated to providing our clients with the best possible care and service. We strive to keep costs for your veterinary care from increasing at an unreasonable rate. We are asking for your help in understanding and cooperating with our financial policy.

All payments are expected at the time of service. Any outstanding balances are due within 30 days unless other agreements have been made with our Business Manager and the owners of Essex Equine, Inc. All payment plans/agreement forms must be completed prior to or at the time of service.

For your convenience, Essex Equine, Inc. accepts cash, checks, Visa, MasterCard, Discover, AMEX, and Care Credit and payments through Venmo, PayPal, and our online portal.

Any unpaid balances after 30 days will be assessed interest at a rate of 1.5% per month (18% annually.) All balances over 90 days past due may be sent to a collection agency. Should your account be sent to a collection agency, you will be financially responsible for all collection fees and legal fees that our office incurs through the process utilized to collect the outstanding balance.

There will be a $30.00 fee assessed for any check returned unpaid by your bank or financial institution.

I HAVE READ AND FULLY UNDERSTAND THE FINANCIAL POLICY SET FORTH BY ESSEX EQUINE, INC. AND I AGREE TO THE TERMS OF THIS FINANCIAL POLICY. I ALSO UNDERSTAND AND AGREE THAT THE TERMS OF THIE FINANCIAL POLICY MAY BE AMENDED AT ANY TIME WITHOUT PRIOR NOTIFICATION TO THE CLIENT.

Credit Card Authorization Form

All clients are requested to keep an active credit card on file with Essex Equine, Inc. Please choose one option below.(Required)
Outstanding Balances

Monthly payments must be at least 15% of total balance to allow clients to remain in good standing with full services provided. If the minimum monthly payment amount is not met services will need to be paid for at the time they are provided until the past due balance has been brought to current.

Total balance owed is not to exceed $5000.00

Photographs

Unless directed otherwise, Essex Equine, Inc., its representatives and employees reserve the right to take photographs of clients and patients, and to copyright, use, and publish the same in print and/or electronically for the purpose of publicity, illustration, advertising, and web content.

Patient Information (#1)

MM slash DD slash YYYY
In this horse insured?
Address of boarding facility
Contact at farm
Do you lease or own?

Patient Information (#2)

MM slash DD slash YYYY
In this horse insured?
Address of boarding facility
Contact at farm
Do you lease or own?

Patient Information (#3)

MM slash DD slash YYYY
In this horse insured?
Address of boarding facility
Contact at farm
Do you lease or own?