needs your help

is a member of AcutePlus. As a part of their membership they are to be considered for credits related to 's most recent procedures administered by you.

In order to be considered for benefit credit, we need you to to complete the following Vet Report.

Veterinarian Information

Veterinarian Name & Practice Name

Incident ID

Invoice #s

Date

Email Address

Phone Number

General Information

Owner/Member Name

Horse Name

Sex

Age

Do you know if this horse is up to date on vaccines?

Are you a regular attending veterinarian?

What is the date of onset for this condition?

When (date/time) did you first examine for this condition?

Have you or anyone else in your practice previously examined this horse?

Does this illness/injury appear to be an entirely new one?

Yes

Is this illness/injury related to or a recurrence of a previous one?

Yes

Where was this animal located at the time of your exam?

What was your diagnosis of the illness or injury?

What was the cause of the illness or injury?

Did you render the initial care?

Please describe the treatment provided

Prognosis

Immediate treatment plan

BY TYPING YOUR NAME IN THE FORMAT INDICATED BELOW IN THE SIGNATURE BLOCK (YOUR NAME WITH THE /S/ BEFORE IT), YOU CONFIRM YOUR INTENT TO SIGN ELECTRONICALLY. YOU AGREE THAT YOU ARE AGREEING TO THE TERMS OF THIS DOCUMENT AND AFFIXING AN ELECTRONIC SIGNATURE. SUCH ELECTRONIC SIGNATURE WILL HAVE THE SAME VALIDITY, ENFORCEABILITY AND ADMISSIBILITY AS A WET INK SIGNATURE. YOU HAVE THE ABILITY TO OPT OUT OF AN ELECTRONIC SIGNATURE. YOU MAY DOWNLOAD, COMPLETE, SIGN AND RETURN THIS FORM TO US VIA FAX AT 561-983-4724. PLEASE BE ADVISED THAT REQUIRING THE TRANSACTION TO BE PERFORMED VIA HARD COPY COULD DELAY MATTERS. WE HAVE THE ABILITY TO PROMPTLY PROVIDE A COPY OF THE ELECTRONICALLY SIGNED DOCUMENT.

Signature

For example: If your name is John Doe, enter /s/John Doe.

Date

Vet Report Has Already Been Submitted

Success

needs your help

Veterinarian Information

General Information