Forms

Veterinary Service Agreement

Thank you for choosing Haymarket Veterinary Service for your horses’ health care needs! Please fill out this form prior to your first visit. It can be submitted online, by email, fax, or handed to the vet at your appointment.

Access the online form here

Horse Owner Information
Lessee Information –If Applicable
Name*
Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell
Cell
Home
Home
Email*
Email*
Date of Lease(From -To)
Stable/Boarding Location
Phone
Equine Insurance Co*
Phone
List*
Horse Name Registered/Show Name DOB Breed Use Color Gender

Payment/Credit Policies
Open communication of fees and financial policy is essential in establishing and maintaining a professional relationship between Client and veterinarian.
- Payment is due at the time of service. As such, a Credit Card is required in order to book an appointment. This Credit Card will be charged for all medications and services rendered by Haymarket Veterinary Service.
- Late Charges: If for some reason a past due invoice is not able to be charged to a credit card a late charge of 1.5% will be applied monthly to the overdue amount.
- Returned Checks: A fee of $50.00 will be applied for any NSF checks.
- Questions: If a client has a question about their account we ask that you bring it to our attention within 30 days. We strive to be forthcoming and honest with our clients and welcome any inquiries that you may have.
Payment Preferences
Please choose your payment preference below:
- Charge my credit card for each invoice
- Charge my credit card at the end of the month
- Payment at time of service–cash, check or credit card at or before the time of service (this also requires completion of the credit card information below)
I would like to receive my invoices via email.
- YES
- NO
Credit Card Information
Card Number
Exp Date
CVV
Select
- Visa
- Master Card
- Discover
- American Express
Name on Card
Authorized Signature
Agreement
I understand and agree that any balances will automatically be billed to my credit card. Authorization to pay any past due balances with my credit card will remain in effect unless I cancel this agreement in writing with 30 days notice. Compounded drugs are not FDA-approved, which means they do not come with the same assurances for safety, quality, and efficacy as FDA-approved drugs. HVS largely relies on approved medications, but we do use compounded medications when there are no approved options available or if potential benefits to the patient outweigh the risks. When you give us permission to treat your horse, you are agreeing that you understand this policy and give permission to prescribe compounded medications to your horse. Photos taken over the course of patient care and management are often used for educational seminars, website articles, and/or social media posts. We retain anonymity of the horse and client unless the client gives permission to divulge that information. When you give us permission to treat your horse, you are agreeing that you understand this policy and give consent for HVS to use such photographs of your horse for these purposes. By signing below, I agree I have read, understand, and voluntarily agree to comply with the terms and conditions of the Agreement as a legally enforceable contract with HVS. I further understand and agree that veterinary services cannot be provided without my initials where requested above and my signature and payment information provided below. If I decline to provide a credit card, I realize that I must provide payment at each appointment and the provisions enumerated above will be in effect for instance of late or non-payment as indicated. Any changes to this agreement must be received in writing.
Client’s Signature
Date
Comments
This field is for validation purposes and should be left unchanged.

Veterinary Services Agreement Form Download

Forms

Veterinary Service Agreement

Access the online form here

Spring Vaccine Information

Access the Online Fillable Form Here

Horse Name	Registered/Show Name	DOB	Breed	Use	Color	Gender