Equine New Client Registration

Our method to process your information: The veterinarian will input patient records into the patient account, then follow with a written summary of the appointment which will be emailed or printed, then the invoice will be emailed to you. Horses examined at the hospital will be presented with summary and invoice before the horse leaves. Our Payment Policy: In order to keep fees as low as possible, payment is due in full at the time of service. For ambulatory cases, in order to give you time to review the invoice, we will use your credit or debit card (which will be securely held on file) the day after your appointment for payment, unless we have received a check or cash for services. For hospitalized horses, a deposit is required prior to hospitalization for elective surgeries and medical treatments of 50% of the estimate, medical or surgical emergencies require a minimum deposit of $1,500. 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 another alternative that might help ease the financial strain when dealing with a medical emergency. Insurance claim payments for a major medical claim will be sent to you directly from your insurance company and you are responsible for payment at the time of service regardless if the insurance company has paid on your claim before your horse leaves CEC. If full payment is not possible, then special arrangements may be made with the business office in advance. We accept care credit depending on the pay off time you have agreed upon with Care Credit. Applications are available at the front desk or on our website. The total balance owed is not to exceed $1,000.00. Accounts overdue 30+ days will incur a 8% per year service charge authorized per month if payment is not received in full by the last day of the month. In addition, a $15.00 rebill charge will be added. Accounts that are past-due over 6 months may be sent to a Collections Agency. Online pharmacy medications must be paid for through the online pharmacy to receive discounts. Medications bought directly from the clinic must be paid for at the time they are dispensed to you. In the case of a pre-agreed upon monthly payment arrangement, we will run your credit or debit card at the end of the month. 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 another alternative that might help ease the financial strain when dealing with a medical emergency. In case you cannot not be contacted: I authorize the Colorado Equine Clinic, PC to provide routine or emergency care to my animal(s) in my absence or at my barn management's request. I understand that any invoices incurred are my responsibility to pay and will 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 Colorado Equine Clinic, PC to set up a payment plan. Should Colorado Equine Clinic, PC be forced to commence administrative or legal action to collect unpaid invoices: I consent to the personal jurisdiction of The 18th Judicial District and Douglas County, Colorado courts. I agree to pay all costs and reasonable attorney's fees incurred by Colorado Equine Clinic, PC that are associated with such action. The undersigned is at least 18 years of age and agrees to the terms of the payment above. Further, in the event of default of payment within these terms, the undersigned agrees to pay all costs of collection including reasonable attorney's fees and court costs. Any animal which is unclaimed by its owner or agent ten days after dismissal shall be deemed to be abandoned and may be disposed of as the Veterinarian may deem proper. I authorize Colorado Equine Clinic, PC to provide veterinary services for my animal(s) listed on the next page(s) of this form. We accept cash, checks, Master Card, Visa, American Express, or Discover. PLEASE NOTE: OUR PRESENT CREDIT CARD COMPANY ISSUES A 3% SURCHARGE FOR CREDIT CARD. 0% FOR DEBIT CARD. Please circle your preferred payment method: Please include your credit/debit card information below for payment at the time of service.