Client and Patient Profile "*" indicates required fields CompanyThis field is for validation purposes and should be left unchanged.Today’s Date* MM slash DD slash YYYY Name*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell Phone*E-mail Address* Driver's License NumberStateExpiration Date MM slash DD slash YYYY Co-Owner/Authorized Person's Name*Emergency Contact*CellHow Did You Hear About Us?*If referred by a friend, whom may we thank?Horses Registered Name*Date Of Birth* MM slash DD slash YYYY SexGeldingMareStallionStable Name*Can we share your horses information with this person? Yes No Stable Full Address*Barn Manager Name*Barn Manager's Phone #*Barn Name (or N/A)*Horse's Location (full address)*Breed*ColorPrevious veterinarian from whom records may be requested:NamePhone Number of Veterinary PracticeHow many additional horses do you have?Select Hours123456I do Do Not Authorize Advanced Equine to Use My/my Horses' Images for Social Media/website/promotional Use. I hereby authorize the veterinarians to examine, prescribe for or treat horses that belong to me or are under my direct care. I assume responsibility for all charges incurred in the care of these animals, including consultation fees for telephone, verbal and written communications and fees for any documentation including outside prescriptions. All unpaid balances will accrue a finance charge of 1.5% per month and a $10.00 billing charge. In the event that fees are not paid as delineated above, I agree to pay any and all collection and/or attorney’s fees incurred:Signature Of Owner Or Agent
