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Online Pharmacy
Careers
Request an Appointment
About
Services
Online Pharmacy
Careers
Request an Appointment
Payment Policy
"
*
" indicates required fields
Your Name
*
First
Last
Your Mailing Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Is your horse's address the same as your mailing address?
*
Yes
No
Please list your horse's address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
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
*
First
Last
Credit Card Number
*
Expiration Date
*
CCV
*
Patient Information
Patient Registered Name
*
First
Patient Barn Name
*
First
Age
*
Breed
*
Color
Sex (Mare, Gelding, Stallion)
Patient Location/Stable Name
Vaccination/Medical History
Any medical conditions Iowa Equine should be aware of?
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Comments
This field is for validation purposes and should be left unchanged.
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