Hospital Admission Form

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Hospital Admission Form

Please fill out this form as completely and accurately as possible so we can get to know you and your equine before your visit.

Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Who else is authorized to make decisions about your equine's healthcare? *

First

Last

Phone

Names and Nicknames *

Age/Date of Birth *

Breed *

Sex *

Male
Neutered Male
Female
Spayed Female

Color *

Age/Date of Birth *

Hay Type and How Much *

Grain Type and How Much *

Submitting Claim for the Visit?

Additional Info *

Specific Treatment/ Diagnostics/ Procedure Expected *

Trainer *

Trainer Contact Info *

We would like to welcome you to Blue Ridge Equine Clinic and THANK YOU for giving us the opportunity to provide treatment/services for your horse. I understand that during the performance of the foregoing procedure(s) or operation(s), unforeseen conditions may be revealed that necessitate an extension of or addition to the foregoing procedure(s) identified, as may be deemed necessary and desirable in the exercise of the veterinarian's professional judgment. I also authorize the use of appropriate anesthetics, and other medication, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian. I have been advised as to the nature of the procedure(s) or operation(s) and the risks involved. I realize that results cannot be guaranteed and that there are inherent risks as well as unforeseen complications that can occur with any medical or surgical procedure. Hospitalized animals have an increased risk of infection and injury which may occur in association with hospitalization, diagnosis, and treatment. Precautions are taken to prevent injuries and acquired sickness and BLUE RIDGE EQUINE CLINIC does not assume costs for treatment. Patients are closely monitored for signs of infection. Reasonable diagnostic testing of clinically affected or suspect animals to detect contagious microorganisms, will be performed at the owner's expense. Apparently unaffected animals may also be tested to allow appropriate management of contagious diseases while at BLUE RIDGE EQUINE CLINIC. Owners are responsible for any costs of special procedures required to manage patients suspected of being infected with contagious microorganisms. Initial estimates are subject to change. Owners will receive updated cost estimates whenever additional testing or precautions are necessary *

I have read and accept the above statment.

1. The owner or duly authorized agent agrees to accept responsibility for full payment of all treatment and services rendered by Blue Ridge Equine Clinic. I do understand the cost stipulated for the projected services is just an estimate and not the final bill. 2. I understand that a 50% deposit of the estimated charges may be required when any patient is admitted to the hospital. 3. I understand and agree that the account balance is due at the time of the animal's discharge from the hospital. **If you think you may need help paying for your hospital invoice, we would like to recommend that you contact CareCredit to apply for payment assistance 1-800-365-8295 (also on line at www.carecredit.com). Through them, we accept 6 months no interest and 24, 36 & 48 month payment plans @ 11.9%. 4. If payment is not made at time of discharge, I authorize BLUE RIDGE EQUINE CLINIC to charge my VISA/MasterCard/Discover credit card to pay balance due for services received. Blue Ridge Equine Clinic must be notified prior to discharge if client wants to use a different credit card than the one identified on the hospital admission sheet. 5. I agree that BLUE RIDGE EQUINE CLINIC may recover its costs, including reasonable attorney's fees, incurred in the enforcement hereof (and collection of sums owed) in addition to any other remedies to which it may be entitled. A finance charge computed at a periodic rate of 2.5% per month (annual percentage rate 18%), will be applied to all accounts unpaid after thirty (30) days. The minimum finance charge will be $1.00. *

I have read and accept the financial policy.

YOUR HOSPITAL INVOICE: Payment in full is required at time of discharge, even for those horses that are insured. Please contact the office to find out your final invoice total prior to discharge and to confirm your preferred method of payment. We accept Visa, MasterCard, Discover, personal check and cash. PROGRESS UPDATES: While your animal is in the hospital, all requests for an update regarding the status of your horse should be directed to the attending veterinarian. He can be reached at (434) 973-7947 during regular office hours. After-hours, you should call the answering service at 434-973-7947 to have the hospital doctor on-call paged. VISITATION POLICY: You may be able to visit your animal while hospitalized with prior consent from the attending veterinarian. Please check in at the reception desk before going to the barn for your visit. DISCHARGE POLICY: Please understand that no animals will be discharged from the hospital without prior arrangement. Once the attending veterinarian has advised you that your horse can go home, please ensure that you speak with the front desk to let them know of your anticipated arrival time for pick up. Please call (434) 973-7947 a half hour prior to your arrival. We would also appreciate pick-ups to occur between 9am and 4 pm whenever possible. ALWAYS check in at the front desk when you arrive to take your horse home. A Late fee may apply for any scheduled pick up after 5 PM or on the weekend. *

I have read and accept the above statement

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Hospital Admission Form

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