Horse's Information
Second Horse Information
Third Horse Information
Fourth Horse Information
Fifth Horse Information
Please include additional horses on the final page.
Services
I hereby authorize Conley and Koontz Equine Hospital (CKE) to provide routine and emergency care to my horse upon my request or upon the request of an authorized agent upon my absences (please initial and complete the Absentee Owner’s with Authorized Agent sections).
I authorize the use of appropriate sedation and/or other medication(s) and I understand that Conley and Koontz Equine Hospital personnel will be utilized as deemed necessary by the attending veterinarian (please initial).
Absentee Owner’s with Authorized Agent
(Trainer/barn owner/lessee etc.)
I authorize my agent to make appointments/request services and order medication for my horse(s) and give him/her permission to charge such appointments/medication to my card on file (please initial).
I authorize the release of my medical information about my horse(s) to ;my agent. (please initial).
Payment/Credit Policy
  • Payment by cash, check, Visa, Mastercard, Discover, American Express, Care Credit, direct withdrawal (ACH), or Venmo is expected and due at time of service.
  • A 5% discount will be applied to payments made with cash, check, or direct withdrawal (ACH), at the time of service.
  • If you are absent during the appointment, arrangements must be made to remit payment. If payment is not received at the time of service, you may be denied current and/or future services.
  • New services cannot be provided, and appointments cannot be made if there is an overdue balance. Invoices that are not paid at the time of service are automatically overdue.
  • All daytime and after-hour emergencies require a deposit to be made before the veterinarian can provide aid to your horse. Daytime emergency deposits are a minimum of $500 and after-hour emergency deposits are a minimum of $750. This deposit can be made by debit, credit card, or direct withdrawal over the phone. If the deposit exceeds the amount due, a refund or credit will be provided.If the deposit does not exceed the amount due, the remaining amount is due at the time of service.
  • Returned checks: a fee of $45 will be applied for any returned checks.
  • No show appointments or same day cancellations may be charged an inconvenience fee of $100.
  • Absentee Owners: All absentee owners must provide a credit card or direct withdrawal information for CKE to keep on file. Payment will be automatically withdrawn immediately after service is provided. A receipt of payment will be emailed or mailed.
  • Cases admitted to the hospital will require a deposit at the time of intake. Additional deposit may be required if the cost of care reaches the initial deposit amount. The balance is to be paid in full before the patient can be discharged.
  • All balances not paid in full will incur a finance charge at the highest level permitted by Indiana law (currently 21% annually). Finance charges will be assessed monthly.
  • Client agrees to pay all costs incurred with collection of debt, any court cost, and/or reasonable attorney fees.
Sign above
Credit Card Information
All clients with an authorized agent are required to have credit card or direct withdrawal information on file. To put a credit card or direct withdrawal information on file, please fill out the information below. If you would prefer to do it over the phone, please call the office on (877) 499-9909. Your signature is required below, even if you provide your information over the phone. This card will be charged after services are provided, unless other arrangements are made.
Sign above
Direct withdrawal (ACH) Information
If you prefer not to leave a credit card on file and choose direct withdrawal from your bank account, please fill out the information below. ACH payments made at time of service receive a 5% discount.
Type of Account
Sign above
check
We believe that effective communication of fees and payment policy is vital to maintaining a good working relationship. If you have any questions or concerns, please bring it to our attention.

To add additional horses:

  1. Click the link below to open the form.
  2. Print it, fill it in by hand, and
  3. Attach the completed form to your submission.

Download & Print Additional Horses Form

One file only.
100 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.
CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.