Veterinary Services Contract

Please note: By submitting this document, you are forming a contract with PIEDMONT 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 unless prior arrangements have been made. A credit card on file is required for all clients who wish to be billed monthly. Insurance claim payments for major medical claim will be sent to you directly from your insurance company.

Client Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Work Phone
Cell Phone*
Email
Electronic Billing
IN CASE YOU CAN'T BE REACHED IN AN EMERGENCY
Name*
First Last
Phone*
Patient Information
Show Name
Barn Name
Age*
Breed*
Color*
Gender
2nd Patient's Name
2nd Patient's Age
2nd Patient's Breed
2nd Patient's Color
2nd Patient's Gender
Insured
Patient's Physical Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Barn Manager/Trainer
Name
Phone
Credit Policy

Payment is expected in full upon receipt of statement.

Credit may be extended at the discretion of The Piedmont Equine Practice.

All overdue accounts are charged 18% interest per annum (charged as 1.5% monthly) if payment in full is not received by 25th of the billing month.

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

Online pharmacy medications must be paid for at the time of pick up or when ordered to receive discounts.

Surgical or Critical Care cases that are admitted to the hospital require a 50% deposit of the high end of the estimate, at admission, and are required to be paid in full at the time of discharge or end of care.

Critical care cases can be expensive. Being prepared financially can ease considerably the emotional burden when making decisions for the well-being of your horse. Please consider possible medical financial support options such as an insurance policy, CareCredit, an emergency credit card or other alternative that might help ease the financial strain when dealing with a medical emergency.
Consent

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

In the event of an emergency and I, the owner, can not be reached I authorize The Piedmont 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 Piedmont Equine Practice to set up a payment plan.

Should The Piedmont 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 Fauquier County,

2.I agree to pay all costs and reasonable attorney's fees incurred by The Piedmont Equine Practice that are associated with such action.
Please sign by entering your name:
I have read, understand and consent to the above terms.
First Last
and enter today's date

Monday	8:00am – 5:00pm
Tuesday	8:00am – 5:00pm
Wednesday	8:00am – 5:00pm
Thursday	8:00am – 5:00pm
Friday	8:00am – 5:00pm
Saturday	Closed
Sunday	Closed

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Veterinary Services Contract

Veterinary Services Contract

Client Information

IN CASE YOU CAN'T BE REACHED IN AN EMERGENCY

Patient Information

Barn Manager/Trainer

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Pet Health

Veterinary Services Contract

Veterinary Services Contract

Client Information

IN CASE YOU CAN'T BE REACHED IN AN EMERGENCY

Patient Information

Barn Manager/Trainer

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Pet Health