Payment Policy

"*" indicates required fields

Your Name*

Your Mailing Address*

Is your horse's address the same as your mailing address?*

Yes

Please list your horse's address

Phone*

Email*

Accept Terms*

1) I must pay at the time of service or have my credit card on file billed on the same day as service is provided. 2) Insured horses: I am responsible for all payments and will then be reimbursed by the insurance company directly. Iowa Equine will fill out all necessary insurance forms. 3) I agree to notify Iowa Equine of any changes in my address, credit card information, or expiration dates, and Iowa Equine is authorized to revise its records accordingly.

I understand.

Name on Card*

Credit Card Number*

Expiration Date*

CCV*

Patient Information

Patient Registered Name*

Patient Barn Name*

Age*

Breed*

Color

Sex (Mare, Gelding, Stallion)

Patient Location/Stable Name

Vaccination/Medical History

Any medical conditions Iowa Equine should be aware of?

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

Payment Policy

Patient Information

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