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Patient Registration and Consent Form
updated 1.31.2019
Client Account Information
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Contact Person
Owner's Name (if different than Contact)
Address (including city, state, zip)
Phone Number
Email address
Barn Information (if different from above)
Barn Contact Person
Barn Address (including city, state, zip)
Barn Phone Number
Patient Information
Patient Name
(A separate form must be completed for each horse)
Breed
Age
Color
Sex
Clear selection
History of illness/injury and current medications
Authorization and Consent for Treatment
Please select one of the following four options:
North Wind Package: physical exam, sedation, full set of baseline dental radiographs, oral exam, float, and any necessary leveling of teeth.
Basic Package: physical exam, sedation, oral exam, float, and any necessary leveling of teeth; no radiographs taken unless an issue is noted on oral exam.
More information on package options can be found here: https://www.northwindequine.com/services-and-pricing-1
Please indicate what should happen if you are not able to be present at your animal's appointment. If you have financial stipulations or other requirements, please add them in "other". *
Please check each of the boxes to indicate your understanding.
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North Wind Equine may use pictures or descriptions of my animal for educational purposes (which may include educational presentations and/or informational posts on social media). *
By typing my name below, I certify that I am the owner (or agent of the owner) of the above listed animal, and I authorize North Wind Equine to provide dental care for the animal (including sedation, examination, and treatment). *
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