Equine Services Request Form

You are here: Home / Forms / Equine Services Request Form

Equine Services Request Form

Form for requesting equine services

Who is requesting service?

Name(Required)
For emergency contact
For messaging appointment confirmation.
For sending an invoice copy and receipt.
Are you an existing client of Rogue Equine Hospital?(Required)
PHYSICAL ADDRESS
Is your mailing address the same as your physical address?
MAILING ADDRESS
Will you be on-site during our visit?(Required)
If you will not be present, we require a card be placed "on file" for payment of service. Credit cards incur a 2.5% fee while debit cards, cash and approved checks do not. Checks must be approved in advance. After you complete this form, you be presented with a secure link to our simple card storage site. We recommend storing a card for your convenience, even if you will be present.
Hidden
You will be directed to a new page. Please return to this page when finished. There will also be a link provided on the confirmation page.

Horse Information

Do you have another horse to add?(Required)

Service Options

Please select from the following services.(Required)
* Highly Recommended // EWTWR = East & West Encephalitis, Tetanus, West Nile, and Rabies // EWTW = East & West Encephalitis, Tetanus, West Nile // FR = Influenza and Rhinopneumonitis (Herpes) // PHF = Potomac Horse Fever
Rogue Equine Hospital Payment Policy and Service Agreement.(Required)
Payment is due at the time of services, or upon presentation of an invoice/statement. In some cases, an estimate may be presented for payment in advance. In all cases, I, the owner or agent, and that person signing this form is responsible for payment. In addition, I understand and agree that in the event of default I may be subject to additional collection and/or attorney's fees when applicable. All disputes to be resolved in Jackson County, Oregon.
Reset signature Signature locked. Reset to sign again

Services we provide

  • Sports Medicine
  • Imaging
  • Acupuncture
  • Chiropractic
  • Reproduction
  • Dentistry
  • Surgery
  • Wellness Program
  • Immunizations
  • Deworming

Visit our online pharmacy

Scroll to top