New Client Form

Name: Brandon Equine Medical Center
Address: 605 E Bloomingdale Ave, Brandon, FL, 33511, United States
Telephone: 813-643-7177
Price range: $

Please fill out this form before your appointment.

Appointment Telemedicine

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Primary Phone *

Secondary Phone

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

First

Last

Phone

How did you find out about our hospital? *

Patient Information

Barn Name *

Registered Name

DOB *

Gender *

Gelding
Stallion
Mare

Breed

Color

Microchip #

Is the Physical Location of the animal different than Owner Address above? *

Trainer/Barn Owner

Trainer/Barn Owner Phone

Do you have insurance? *

Financial Policy

All invoices must be paid for at time of service with the following payment options:

• Payment due in full by cash, check or credit card at the conclusion of your appointment, or at discharge
• We accept Visa, MasterCard, Discover, American Express and CareCredit. For those clients who cannot be present at the time of service, you can provide your credit card information, or you may leave a form of payment with your agent/barn owner/etc.
• You may provide credit card information to the office to keep on file through an electronically secure system. Those choosing this method will have their credit cards charged and a receipt emailed to them.
• A $30 returned check fee will be issued for all returned checks.
• In the event that your horse is hospitalized, a deposit is required upon admission and the balance is due at time of discharge or case resolution. You will be required to sign a Financial Contract at time of hospitalization.

Photographic Release Waiver

There may be times when Brandon Equine Medical Center's staff, the media, or other organizations, with the approval of Brandon Equine, may take photographs of patients or videotape patients. Those photographs and/or videotaped images (without patient identification information) may appear in veterinary medical publications, on the Brandon Equine website, on a Brandon Equine social media outlet, in the news media, or in other equine-related organizations' publications.

I hereby grant Brandon Equine Medical Center permission to use my horse's photograph and/or videotaped image for the purposes mentioned above.
I do NOT grant Brandon Equine Medical Center permission

Signature below authorizes treatment and is a guarantee of payment for all charges. *

Clear Signature

Phone

Expert equine care in Brandon, FL.

From our board-certified horse surgeons and board-certified internists to our professional and courteous staff, at Brandon Equine Medical Center, we are committed to the health and well-being of all breeds and sizes of horses. In the field, as an outpatient, or when admitted to the horse hospital, we treat every horse like our own and every client as the most important.

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Contact Info

Phone: 813-643-7177
Fax: 813-643-5877
Email: info@brandonequine.com

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Hours

Monday – Friday: 8AM-5PM
Saturday & Sunday: Closed
Emergency care available: 24/7/365

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Location

605 E Bloomingdale Ave
Brandon, FL 33511
Click here for directions.

Have a question?

Our team is here to help! Complete the form below to get in touch.
If this is an emergency, please call us directly at 813-643-7177.

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