Patient Registration and Consent Form

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

updated 1.31.2019

Client Account Information

YYYY

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

Gelding

Mare

Stallion

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". *

Unless I specify otherwise, I'd like my animal to have the North Wind Package option, which includes baseline and diagnostic radiographs. If an issue is noted on the exam, the veterinarian should do whatever is necessary to diagnose and treat my animal, including performing any minor extractions (such as wolf teeth, caps, expired, or mobile teeth) at their discretion. I understand there will be additional costs associated with this.

Unless I specify otherwise, I'd like my animal to have the Basic Package option, which does not include baseline radiographs. If an issue is noted on the exam, the veterinarian should do whatever is necessary to diagnose and treat my animal, including taking any necessary diagnostic radiographs and performing any minor extractions (such as wolf teeth, caps, expired, or mobile teeth) at their discretion. I understand there will be additional costs associated with this.

Ask me before each appointment which package option I'd like. If an issue is noted on the exam, the veterinarian should call me for permission to perform any additional procedures, such as radiographs or minor extractions. I understand that if I am not able to be reached, these additional procedures will not be carried out.

Unless I specify otherwise, I'd like my animal to have the Basic Package option, which does not include baseline radiographs. The veterinarian should not perform any additional procedures beyond the exam and treatment I requested when making the appointment.

Other:

Please check each of the boxes to indicate your understanding.

As dental work is an elective procedure, I understand that North Wind Equine will do everything possible to reduce the risks by not working on animals when it's not safe to sedate them (for example, if they're pregnant, have uncontrolled heaves, or are experiencing an active founder episode). However, I understand that there are always risks involved in veterinary dental procedures. I authorize North Wind Equine to administer appropriate sedation and pain relief medication as needed before, during, and after the procedure. I understand that if I have further questions about the procedure, I am encouraged to ask the veterinarian.

Required

I direct that the instructions on this consent form with respect to the treatment of my animal shall continue to apply to all treatment provided to my animal until I notify North Wind Equine of a change in my instructions.

Required

I understand that payment is due at time of service in order to avoid a late fee of 20%.

Required

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). *

Yes, go ahead!

No thanks!

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). *

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms