New Client Form

Client Name

First Last

DOB

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Place of Employment

Phone

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Please Choose One:(Required)

I agree to electronic billing. Please email any invoices and billing statements to the above email address. I agree to keep my email address up to date.

I would like to receive paper invoice and billing statements through the mail.

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)

Option 1: Autopay I authorize Essex Equine, Inc. to keep on file and charge the credit card that is on file for all services provided. I agree that this credit card will be charged for the full balance of my account after each service. I agree to keep my credit card up to date.

Option 2: Credit Card on file I authorize Essex Equine, Inc. to keep on file the credit card that has been or will be provided. I will authorize payment after each service. I agree that if I have not made other payment arrangements within 30 days of service, this credit card will be charged for the full balance of my account. I agree to keep my credit card up to date.

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)

Registered / Show Name

Barn Name

Patient Date of Birth

Breed

Color

Gender

In this horse insured?

Yes

I don't know

Medical Conditions

Current Medications

Type of training workload

Name of boarding facility

Boarding facility phone number

Address of boarding facility

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact at farm

First Last

Do you lease or own?

Lease

Own

If lease, please provide owners name and contact information

Emergency contact name and phone number who you've allowed to make decisions about your horse

Any additional information we should know about pertaining to your horse?

Patient Information (#2)

Registered / Show Name

Barn Name

Patient Date of Birth

Breed

Color

Gender

In this horse insured?

Yes

I don't know

Medical Conditions

Current Medications

Type of training workload

Name of boarding facility

Boarding facility phone number

Address of boarding facility

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact at farm

First Last

Do you lease or own?

Lease

Own

If lease, please provide owners name and contact information

Emergency contact name and phone number who you've allowed to make decisions about your horse

Any additional information we should know about pertaining to your horse?

Patient Information (#3)

Registered / Show Name

Barn Name

Patient Date of Birth

Breed

Color

Gender

In this horse insured?

Yes

I don't know

Medical Conditions

Current Medications

Type of training workload

Name of boarding facility

Boarding facility phone number

Address of boarding facility

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact at farm

First Last

Do you lease or own?

Lease

Own

If lease, please provide owners name and contact information

Emergency contact name and phone number who you've allowed to make decisions about your horse

Any additional information we should know about pertaining to your horse?

Credit Card Authorization Form

Patient Information (#1)

Patient Information (#2)

Patient Information (#3)

Our Location

Office Hours

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