FOX RUN EQUINE CENTER

394 Fox Road Brian S. Burks, D.V.M.

Apollo, PA 15613 Diplomate A.B.V.P.

Phone: 724-727-3481

Fax: 724-727-7436 www.foxrunequine.com

24 HOUR 7 DAYS A WEEK FULL SERVICE EQUINE HOSPITAL

HOSPITAL ADMISSION AGREEMENT AND CONSENT I, the undersigned, do hereby certify that I am the owner, lease and/or agent of the animal identified herein and that I

hereby authorize Fox Run Equine Center to evaluate, assess, treat and/or preform procedures (Medical, Surgical, and

Breeding) which are deemed necessary by the attending veterinarian. I further authorize and certify that the nature and

performance of procedures medical or surgical, identifiable alternative methods, and treatments carry certain risks and

possible complications. These have been fully explained to me and are understood by me. I also recognize there are no

guarantees or assurances for 100% success with any reproductive, medical or surgical procedure.

PAYMENT POLICY

I (the owner or duly authorized agent thereof) agree to accept responsibility for full payment of all breeding,

treatments, surgeries and/or services rendered by Fox Run Equine Center, regardless of the accuracy of the fee

approximation shown. I agree to pay a deposit of no less than 50% of the initial fee estimate when the horse is

admitted to Fox Run Equine Center. I agree to pay the balance of the fees due before the release of the horse from

Fox Run Equine Center. If other financial arrangements are needed, I will contact the office manager of Fox Run

Equine Center prior to bringing the horse to Fox Run Equine Center. We accept cash, personal checks, and money

orders, Visa, MasterCard and CareCredit. If it is necessary to bring an action to compel the payment of fees or costs,

the undersigned shall pay all costs incurred in collection of the debt and reasonable attorney fees. An animal that is

left at the hospital over five (5) working days without communication from the owner/agent, beyond the

recommended dismissal date is considered abandoned. Every effort will be made to contact the owner during this

period of time. At this point the animal will become the property of Fox Fun Equine Center. The initial fee estimate

is $_____________. The owner/agent will be contacted if the charges go beyond this agreed upon amount.

ADMITTANCE-VISITING-DISCHARGE POLICY

I understand that no horse will be brought to Fox Run Equine Center without prior agreement as to time and date.

I understand that I may be able to visit my horse at Fox Run Equine Center between the hours of 11:00am and

4:00pm Monday – Friday and 11:00am and 12 noon on Saturdays or by other arrangements.

I understand that no horse will be discharged from Fox Run Equine Center without prior agreement as to time and

date.

I hereby state that I have read and understood this authorization and release and acknowledge receipt of a copy

thereof. If signing as agent of the owner, the undersigned warrants that he/she has authority to bond the owner.

OWNER/AGENT_________________________________________________ DATE__________________________

EMERGENCY NUMBER_________________________________________________

AUTHORIZATION & RELEASE: I acknowledge that I have been informed that fees for the treatment that may be

rendered to this animal are approximate.

OWNER/AGENT SIGNATURE_________________________________________________

FOX RUN EQUINE CENTER

Page 1 of 3

394 Fox Road Brian S. Burks, D.V.M.

Apollo, PA 15613 Diplomate A.B.V.P.

Phone: 724-727-3481

Fax: 724-727-7436 www.foxrunequine.com

24 HOUR 7 DAYS A WEEK FULL SERVICE EQUINE HOSPITAL

VETERINARY SERVICES CONTRACT Please note: By signing this document, you are forming a contract with FOX RUN EQUINE CENTER. This contract creates certain rights and

obligations including, but not limited to, those described on the third page of this contract. Payment is required at the time of service.

Insurance claim payments for a major medical claim will be sent to you directly from your insurance company.

AAA

**Fox Run Equine Center has my permission to use the photograph of my animal, profile and/ or story on their

website and other promotional materials produced, used by and representing Fox Run Equine Center. I understand

the circulation of the material could be worldwide and that there will be no compensation to me for this use.

Signature: _______________________________ Date:___________________

OWNER INFORMATION:

NAME:______________________________________SPOUSE:_______________________________

ADDRESS:__________________________________________________________________________

CITY:_____________________________________STATE:_____________ZIP:___________________

Same as shipping address? Yes No – If no, address:__________________________________

HOME PHONE:________________________________CELL:_________________________________

EMAIL:___________________________________ PREFERRED CONTACT METHOD______________

EMPLOYER NAME:________________________________WORK PHONE:______________________

In case of emergency, please contact: __________________________________________________

STABLE INFORMATION: SAME AS OWNER ADDRESS? Yes No – If No, complete this section

STABLE NAME:_____________________________________________________________________

CONTACT NAME: (BARN OWNER, AGENT, MANAGER)_______________________________________

ADDRESS:_________________________________________________________________________

CITY:______________________________STATE:__________________ZIP:_____________________

PHONE: (BARN NUMBER)_______________________CELL:__________________________________

EMAIL:____________________________________WEBSITE:________________________________

I authorize the release of medical information about my horse(s) to my barn manager/agent.

Yes No

I authorize my barn manager to act as agent to make appointments and order medications for

my horse (s) Yes No

FOX RUN EQUINE CENTER

Page 2 of 3

394 Fox Road Brian S. Burks, D.V.M.

Apollo, PA 15613 Diplomate A.B.V.P.

Phone: 724-727-3481

Fax: 724-727-7436

www.foxrunequine.com

HORSE INFORMATION Do you Own or Lease this horse?

REGISTERED NAME:____________________________________ BARN NAME:______________________

DATE OF BIRTH/AGE:_________________ BREED:______________________ GENDER _______________

COLOR (S):__________________________MARKINGS: _________________________________________

Registration#:__________________________________Tattoo#:_________________________________

Brands:_______________________________________Microchip#_______________________________

Does this horse have multiple owners: No Yes

Has this horse ever been treated previously by our clinic? No Yes

Is this horse insured? No Yes If yes, please complete the insurance information below.

INSURANCE COMPANY NAME:_____________________________________________________________

PHONE:__________________________ POLICY #:____________________________________________

REASON FOR VISIT: _____________________________________________________________________

RELEVANT MEDICAL HISTORY (EX: Colic, Cushings)____________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

FEED: Product______________________________ Amount______________________ Hay__________

MEDICATIONS:_______________________________SUPPLEMENTS______________________________

BREEDING HISTORY (IF ANY)______________________________________________________________

VICES? Kicks No Yes Bites No Yes Cribs No Yes Other:_______________________

VACCINE HISTORY: * Vaccine and medical records can be attached from previous veterinarian *

E/W Enceph Tetanus – Date ____________________ West Nile Virus – Date_______________________

Rhino/Flu – Date_____________________________ Rabies – Date______________________________

Potomac – Date______________________________ Strangles – Date____________________________

Botulism – Date ______________________________ Other – Date_______________________________

Coggins Testing? No Yes Date:________________ Please attach a current copy

DEWORMING HISTORY: Product: ______________________________Date:_______________________

FECAL TESTING: Date:____________________Results:_________________________________________

Additional Information: (Drug Allergies etc.)_________________________________________________

Owner/Agent Signature Authorizing Treatment______________________________________________

FOX RUN EQUINE CENTER

*** VETERINARY SERVICES WILL NOT BE PROVIDED WITHOUT YOUR

SIGNATURES AND INITIALS***

Page 3 of 3

394 Fox Road Brian S. Burks, D.V.M.

Apollo, PA 15613 Diplomate A.B.V.P.

Phone: 724-727-3481

Fax: 724-727-7436

www.foxrunequine.com

FINANCIAL POLICY *Please initial after each statement*

Payment Options:

1. PAYMENT AT THE TIME OF SERVICE: Payment is required at the time services are rendered. For your convenience, we accept cash, check, Visa, MasterCard, Discover and CareCredit. Note: Clients with horses at boarding, training or breeding stables would need to leave payment at the stable to pay each time services are rendered –OR– the client may keep a credit on their account to pay for services rendered. 2. CHECK PAYMENT/MONTHLY BILLING: (Secured with credit card on file) Please keep my credit card number on file and send me a statement for review on the 15th of each month. If I have not sent payment in full by the 10th of the following month, Fox Run Equine Center has my permission to charge my credit card on the 14th of that month for the account balance. A receipt will be sent out by mail. ** Please note that all charge accounts must be paid in full each month.** 3. PRE-APPROVED CREDIT CARD PAYMENT: Please keep my credit card number on file, charge the credit card each time services are rendered. Send me a receipt and itemized invoice by mail. 4. CARECREDIT : Please keep my CareCredit card number on file. Charge my CareCredit account each time services are rendered. Send me a receipt and itemized invoice by mail. 5. We reserve the right to charge your Visa/Mastercard/Discover/Care Credit card for any outstanding balances.

1. I understand that I must pay all accounts in full upon receipt of invoice and all hospital stays must be paid

before discharge. Initial: _______

2. I hereby authorize Fox Run Equine Center, to provide routine and emergency care to my horse(s) in my

absence or at the request of my barn management/trainer/agent. Yes____ No____ Initial:__________

3. This contract shall apply to any and all veterinary services provided by Fox Run Equine Center, including but

not limited to out-patient services, procedures, medications and farm calls to any and all horses on your

behalf, whether or not the horse (s) are listed on page two of this form. Initial:________

4. I would like to receive my invoices/statements via email Yes_____ No_____ Initial:_____

5. When selecting payment Option 2: If we have not received payment in full within 30 days of invoice, we

understand that signals your consent to have your account settled by immediately charging the balance to

your credit card. Initial: _____

6. When selecting payment Option 3: If your wish is for us to automatically charge your credit card on a monthly

basis, we will agree to do that. Any time a charge is applied to your credit card, we will send you a statement

and invoice for your records. Yes_____ No _____ Initial:______

7. Late charges shall be applied to all accounts overdue at a rate of 1.5% monthly. Initial:______

8. Should Fox Run Equine Center be forced to commence administrative and/or legal action to collect unpaid

invoices from you, a.) You consent to personal jurisdiction of the courts of the State of Pennsylvania and b.)

agree to pay all costs, expenses and reasonable attorney’s fees incurred by Fox Run Equine Center that are

associated with such action. Initial:_______

9. You represent that you are presently able to comply with the payment terms herein, and that if you

should become unable to make timely payment of outstanding invoices, you will contact Fox Run Equine

Center. Initial_______

Owner/Agent Signature_____________________________________________________________________