"*" indicates required fields New Client's Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone #*Cell #*Work #*Email* Barn Manager NameBarn Manager Phone #Is your barn manager authorized to schedule appointments?YesNoFarrier NameFarrier Phone #BarnGatecodeBarn Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Do you own this horse?* Yes No Is this horse leased? Owner's Name if Leased*Horse's Registered Name*Horse's Barn Name*Breed*DOB/ Age**Ensure an accurate date is entered for any future Coggins.SexColorFor multiple patients, please list the same information from the list above for each horse.Financial Policy Consent*Payment in full is due at the time services are rendered. A receipt will be emailed when your card is charged. A valid credit card MUST be kept on file. Client is responsible for updating credit card information on file. Cards may be udpated and added by calling our office. Client authorizes and acknowledges receipt of services and/or medications rendered. Unpaid balances will be subject to finance charges of 1.5% per month. Any costs incurred as a result of non-payment of any bills, including interest, attorney's fees and court costs will be sustained by the client. I have read, understand and agree to the terms contained herein: I agree to the financial policy.Please provide the credit or debit card information that you would like to keep on file:*Card Number :Expiration Date :Card Identification Number: Add RemoveSignature*Please upload any previous veterinary records for your horse(s)File Drop files here or Select files Max. file size: 256 MB. NameThis field is for validation purposes and should be left unchanged.
