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Small Animal

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About Us
Services
Wellness Plans
Resources
News
Contact
Small Animal

Veterinary Services Agreement

"*" indicates required fields

All new clients must pay for their first appointment by cash or credit card. Payment is required at the time of service.

Horse Owner Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Cell Phone*

Home Phone

Work Phone

Email*

Preferred communication method? (please select one or more)*

Authorized Agent*

First Last

Relationship to owner*

Phone*

Email

I authorize my agent to make appointments and order medication for my horse and give him/her permission to charge such appointments/medications to my credit card*

Yes

No

I authorize the release of medical information about my horse(s) to my agent*

Yes

No

Horse #1 Information

Horse's Barn Name*

Horse's Registered Name*

Breed*

Color*

Gender*

Mare

Gelding

Stallion

Date of Birth*

MM slash DD slash YYYY

Stable*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Would you like to add another horse?

Yes

No

Horse #2 Information

Horse's Barn Name*

Horse's Registered Name*

Breed*

Gender*

Mare

Gelding

Stallion

Date of Birth*

MM slash DD slash YYYY

Stable*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Would you like to add another horse?

Yes

No

Horse #3 Information

Horse's Barn Name*

Horse's Registered Name*

Breed*

Gender*

Mare

Gelding

Stallion

Date of Birth*

MM slash DD slash YYYY

Stable*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Would you like to add another horse?

Yes

No

Horse #4 Information

Horse's Barn Name*

Horse's Registered Name*

Breed*

Gender*

Mare

Gelding

Stallion

Date of Birth*

MM slash DD slash YYYY

Stable*

Address*

Street Address City State / Province / Region ZIP / Postal Code

I authorize my agent to make appointments and order medication for my horse(s) and give him/her permission to charge such appointments/medications to my credit card.*

Yes

No

I authorize the release of medical information about my horse(s) to my agent.*

Yes

No

Account Information

I understand that I must pay all accounts in full upon receipt of invoice.*

I understand.

I would like to sign up for EZ pay to have my bills automatically charged to the credit card I have on file. Any time a charge is applied to your card, we will send you an invoice for your records.*

Yes

No

I hereby authorize Premier Equine Veterinary Service to provide routine and emergency care to my horse(s) whether or not the horse is listed above in my absence or at the request of my barn management/trainer/authorized agent.*

I authorize.

You represent that you are presently able to comply with terms herein, and that if you should become unable to make timely payment of outstanding invoices, you will notify Premier Equine Veterinary Service.*

I agree.

All accounts that remain unpaid afer 30 days are considered past due. A late fee of 2% per month. Client shall pay all costs and expenses, including reasonable attorney’s fees and collection fees, which are incurred by Premier Equine Veterinary Service to collect any past due accounts.*

I agree.

Consent*

I agree to the privacy policy.

Signature*

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

15434

Contact Us

Mailing Address:
16935 W. Bruce Road.
Lockport, IL 60441

Picking Up?
Please contact us for the address.

Phone: 888-860-0244
Fax: 888-860-0244
Text: 630-984-5221
Contact Us Online

Hours

Open 24hours for Emergencies

Mon-Fri: 8am-5pm
Sat: By Appointment
Sun: Closed

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