Client Contract

Client Information

Name*

First Last

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Work Phone

Cell Phone

Horse Information

Show Name

Barn Name*

Age*

Breed*

Color*

Sex*

Stable*

Phone*

Authorized Agent*

Phone*

Emergency Contact*

Phone*

Relevant Medical History

Previous Veterinary Practice

Insurance Company*

Phone*

Policy #*

Emergency Phone #*

Account Information

1. I understand that I must pay all accounts in full within 30 days of invoice.

I Consent

2. 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 card, we will send you a statement and invoice for your records.

Yes
No

3. 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.

I Consent

4. I hereby authorize Dunbarton Equine to provide routine care to my horse(s) in my absence or at the request of my barn management.

I Consent

5. This contract shall apply to any and all veterinary services provided by Dunbarton Equine, to any and all horses on your behalf, whether or not the horse(s) are listed on page one of this form.

I Consent

6. Late charges shall be applied to all accounts overdue at a rate of 1.5% monthly or 18% per annum.

I Consent

7. Should Dunbarton Equine be forced to commence administrative and/or legal action to collect unpaid invoices from you:

I Consent

a. consent to personal jurisdiction of the courts of the State of Connecticut over you.

I Consent

b. agree to pay all costs, expenses and reasonable attorney’s fees incurred by Dunbarton Equine that are associated with such an action.

I Consent

8. 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 Dunbarton Equine.

I Consent

I have read and understand Dunbarton Equine's rules, regulations and policies*

I agree

CREDIT CARD INFORMATION

**VETERINARY SERVICES WILL NOT BE PROVIDED WITHOUT SIGNATURE AND INITIALS**

Card #

Exp Date

Name on Card

Security Code

Signature

Date

Guardian’s Signature

Owner Under 18 Years of Age

Name

Dunbarton Equine, PO Box 3637, Newtown, CT 06470 Phone:(203)775-5561 FAX: (203)775-0346

Client Contract

Client Contract

Client Information

Horse Information

Account Information

CREDIT CARD INFORMATION

Contact Us

EquiHealth Login

EquiHealth Resources

New Clients

Client Contract

Client Contract

Client Information

Horse Information

Account Information

CREDIT CARD INFORMATION

Share

Contact Us

EquiHealth Login

EquiHealth Resources

New Clients