P.O. Box 998 • Lake Zurich, IL • 60047
www.lakecountyequine.com • [email protected]
Gary P. Koehler, DVM
Laurel A. Meininger, DVM
847.650.9242
847.975.6831
VETERINARY SERVICE AGREEMENT
Horse Owner Information
Name: ______________________________________
Phone: ___________________ (H, C, W)
Address: ____________________________________
Alt. Phone: ________________ (H, C, W)
City: _______________________________________
State: ______ Zip: _________
Email Address: ___________________________________________________________
Horse Information
Horse’s Name: ______________________________
Age: _____
Breed: __________________
Alt. Name: ___________________
Color: ____________ Gender: _____
Tattoo: ______________
Location: ____________________________________________________________________
Authorized Agent: ___________________________
Phone: ________________________
Emergency Contact: _________________________
Phone: ________________________
Has this horse been treated with any medications in the last 60 days? (This can include oral, intramuscular, intravenous,
or intra-articular injections)
YES
NO
If so, what? __________________________________________________________________
Insurance Company (if any): _____________________________________________________
Policy #: _______________________
Insurance Phone Number: _____________________
**Payment is required at the time of service. Any payment from a medical claim will be sent to you directly, as we do not
bill the insurance company.**
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Lake County Equine Practice, LLC
P.O. Box 998 • Lake Zurich, IL • 60047
www.lakecountyequine.com • [email protected]
Gary P. Koehler, DVM
Laurel A. Meininger, DVM
847.650.9242
847.975.6831
Terms and Conditions
Please initial after each statement
1.
This contract shall apply to any and all services provided by Lake County Equine Practice,
LLC, to any and all horses on your behalf, whether or not the horse(s) are listed on the first
page of this form.
______
2. I understand that I must pay all accounts in full at the time of service.
If a credit card is provided, and you wish to have it charged at the time of service, we will
agree to do so. Any time a charge is applied to your card, we will send you an invoice and
receipt for your records. Credit card on file?
YES
NO
(If yes, please fill out a credit card authorization form)
______
3. I hereby authorize Lake County Equine Practice, LLC and its veterinarians to provide routine
& emergency care to my horse(s) at my request or at the request of my agent (listed on front).
I hereby authorize and direct Lake County Equine Practice, LLC and its veterinarians to
perform the procedures, diagnostics, and/or treatments that are agreed upon by myself or
agent at the time of service. I understand no guarantee has been made as to results or cure. I
understand that there may be risks involved in some of these procedures.
______
4. I represent that I am able to comply with the payment terms set forth herein, and that if I
should become unable to make timely payment of outstanding invoices, I will contact Lake
County Equine Practice, LLC.
______
Legal Owner’s Name (print): ______________________________________________________________
Owner/Authorized Agent’s Signature: ______________________________________________________
Guardian’s Signature (if owner is under 18 years old): _________________________________________
Date: ______________________
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Lake County Equine Practice, LLC