To be considered an ESTABLISHED client of PenMar Equine

your horse must be seen by PenMar Equine at least ONCE yearly

for a CORE Vaccination and Routine Vaccine Exam

OUR FINANCIAL POLICY

Unfortunately, due to an increase in long-standing and unpaid balances, we are no longer able to provide services for any horse, that is not life saving, without an agreed-upon payment schedule.

Prompt payment for services and products is expected, in full, at the time of your appointment. You will receive a verbal treatment plan or estimate before any services are performed, which will give you a cost range of the recommended medical treatment for your horse. If you require a written estimate, please let your treating veterinarian know.

Additional Services Rendered:

• No additional (non-urgent) services shall be provided if accounts are 30 days past due in payment

• No additional (non-urgent) services shall be provided if account balance total is over $400

• If any urgent, emergency services are required, an additional 50% of that invoice will be due at the time of the ER visit

For your convenience, PenMar Equine accepts ALL credit cards, debit cards, checks (with Drivers License # for new/unknown clients) and cash.

Prior to your first appointment, please print and fill out the Vet Services Agreement Form below (in its entirety). If you wish to receive a copy, please let us know and we will gladly provide one.

Veterinary Services Contract

Please note: By submitting this document, you are forming a contract with PENMAR EQUINE PRACTICE. This contract creates certain rights and obligations including, but not limited to, those described in this contract.

Payment is required at the time of service. A credit card on file is required for all clients who wish to be automatically billed. Insurance claim payments for major medical claim will be sent to you directly from your insurance company.

Consent to Treat

I authorize the PenMar Equine Practice to provide routine care to my animal(s) in my absence or at my barn management (or caregivers) request.

In the event of an emergency and I, the owner, can not be reached I authorize PenMar Equine Practice to provide emergency care to my animal.

I understand that any invoices incurred are my responsibility to pay and should be paid in full upon receipt.

I represent that I am presently able to comply with the payment terms herein, and that if I should become unable to make timely payment of outstanding invoices, I will contact the PenMar Equine Practice immediately.

Should PenMar Equine Practice be forced to commence administrative or legal action to collect unpaid invoices:

1. I consent to personal jurisdiction of The Circuit Court of Frederick County,

2. I agree to pay all costs and reasonable attorney's fees incurred by PenMar Equine Practice that are associated with such action.

Client Information

First Name

Last Name

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Address Where Horses are Located

Phone

(###)

###

####

Optional Phone

(###)

###

####

Horses Name

Add Barn AND Show Name if Desired

Gender

Age

Breed

Color

Discipline (What do you use your horse for?)

Additional Horses (Name, Age, Breed, Color, Discipline)

Emergency Contact Name

Should you be unavailable in case of Emergency

First Name

Last Name

Emergency Contacts Phone

(###)

###

####

Barn Managers Name/Trainer

First Name

Last Name

Barn Manager/Trainer Phone

(###)

###

####

Is the person listed above able to make Emergency decisions about the care of your horse?

Initial that you understand the above financial agreement:

For Credit Card on File:

Last 4 digits of CC on file (Full Number to be given over phone)

Cardholder Name:

Expiration Date:

Cardholder Zip:

I authorize PenMar Equine to charge my CC above for agreed upon services. I understand that my info will be stored on file for future use (Please type your name in the box below to acknowledge)

I would like my Credit Card run AUTOMATICALLY after services are provided:

PLEASE SIGN BY ENTERING YOUR FULL NAME:

I have read, understand and consent to the above terms:

Todays Date

YYYY

PLEASE NOTE: YOUR HORSE MUST HAVE BEEN SEEN BY PENMAR EQUINE TO BE CONSIDERED A CLIENT. SIMPLY FILLING OUT PAPERWORK WITHOUT AN APPOINTMENT WILL NOT CONSTITUTE A VETERINARY/CLIENT/PATIENT RELATIONSHIP.