Client and Patient Registration Form
Skip to Horse Information if you've filled out this form before and just need to provide authorization for an additional horse.
Client Account Information
Today's Date
MM
/
DD
/
YYYY
Contact Person
Your answer
Owner's Name (if different from Contact)
Your answer
Address
Your answer
Phone Number
Your answer
Email Address
Your answer
Barn Information (if different from above)
Barn Contact Person
Your answer
Barn Address
Your answer
Barn Phone Number
Your answer
Horse Information
Horse's Name
Your answer
Breed
Your answer
Age
Your answer
Color
Your answer
Sex
History of illness/injury and current medications
Your answer
Authorization for Treatment and Diagnosis
Please select the appropriate option and indicate any special instructions for the doctor if you cannot attend your horse's appointment.
I would like annual dental radiographs (x-rays) to be taken of the above listed animal. I understand that there is an additional fee associated with this.
If radiographs are recommended by the veterinarian to diagnose and determine treatment of the above horse, I authorize this to be done. I understand that there is an extra fee associated with this.
If a minor extraction is recommended by the veterinarian, I authorize this be performed. This may include wolf teeth, caps, expired or mobile teeth. I understand that there is an extra fee associated with this and follow up treatments may be needed.
Please add any additional information you would like the doctor to know for your horse's appointment. Note: As dental work is an elective procedure, we do not work 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).
Your answer
By signing below, I authorize sedation, examination and treatment for the above listed animal. I understand that payment is due at time of service.
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms