Gary P. Koehler, DVM Laurel A. Meininger, DVM Page 1 of 2 Lake
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.** Page 1 of 2 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: ______________________ Page 2 of 2 Lake County Equine Practice, LLC
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