Patient Registration and Consent Form
updated 1.14.2019
Client Account Information
Today's Date *
MM
/
DD
/
YYYY
Contact Person
Your answer
Owner's Name (if different than Contact)
Your answer
Address (including city, state, zip)
Your answer
Phone Number
Your answer
Email address
Your answer
Barn Information (if different from above)
Barn Contact Person
Your answer
Barn Address (including city, state, zip)
Your answer
Barn Phone Number
Your answer
Patient Information
Patient Name
(A separate form must be completed for each horse)
Your answer
Breed
Your answer
Age
Your answer
Color
Your answer
Sex
History of illness/injury and current medications
Your answer
Authorization and Consent for Treatment
Please select one of the following three options:
Please indicate what should happen if you are not able to be present at your animal's appointment. If you have financial stipulations, please add them in "other". *
Please check each of the boxes to indicate your understanding.
*
Required
*
Required
*
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). *
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). *
Your answer
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