Clients | balancedcareequine

New Client Registration

Client Information

First Name

Last Name

Select an Address

Phone

Patient Information

Patient Name

Patient Breed

Patient Age/DOB

Select an option

Male Castrate

Male

Female

Location of Patient (Farm Name and Address):

Patient History (Please give any medical history available. You may also email records to the office prior to first appointment):

Authorized Agents

In the event you are not able to be present for your appointment, please list any persons authorized by the owner to approve care for the patient and a dollar amount up to which care may be authorized for.

Authorized Individual

Phone

Relationship to Owner/Patient:

Dollar Amount Care is Authorized For:

In the event of an emergency where the owner is unreachable, is the above listed individual authorized to make life or death decisions regarding the patient?

Yes

Financial Responsibility

I acknowledge legal ownership of and financial responsibility for the above listed patient. I acknowledge that as the owner of the above listed patient I am responsible any costs incurred in the course of treatment and that payment is due at the time of service. Finance charges will be applied to balances outstanding greater than 30 days.

Your Signature

I accept terms & conditions

Thank you for submitting!