Stillmeadow Equine Client Information Form

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Name *

Address

City *

State

Zip Code *

Cell Phone *

Home Phone

Email Address *

Prefered Contact Method *

Phone

Text

Emergency Contact Information

Emergency Contact (Trainer, Family member, Lessee, Etc) *

Emergency Contact Phone number
*

I authorize this person to make medical decisions in my absence. I am aware that I am financially responsible for treatments authorized in my absence
*

Payment Information

We accept Cash, Check, Visa and Mastercard.

Please select from Payment options below:
*

I authorize Stillmeadow Equine to run my card within 48hrs of rendered service

I prefer to receive an itemized invoice via Email and agree to pay within 30 days of my appointment

I prefer to receive an itemized invoice in the mail and agree to pay within 30 days of my appointment

I prefer to receive a call with the invoice total before running my card on file

If you selected option 6 please explain other payment options

Payment Policy *

I understand that payment is due within 30 days of rendered service(s). If payment is not received within this amount of time, I agree that my provided card will be run, and I will no longer be able to have services performed until my bill is paid in full

Required

Credit Card Information

Visa or Mastercard Only

Name on Card *

Card Number *

Expiration Date *

CVV code *

Client Agreement

I agree to treat every member of the Stillmeadow Equine team with respect and consideration. If failure to do so, I understand that Stillmeadow Equine reserves the right to discontinue services.
*

I Agree

Required

If I need to cancel or reschedule my appointment for any reason, I agree to contact Stillmeadow Equine 24 hours prior to my scheduled appointment time. If I fail to do so, I understand that I will be charged a cancellation fee.
*

I Agree

Required

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