New Client Form | Dutchess County, NY

Client and Patient Profile

Today’s Date

Name

Street Address

City

Zip Code

Home Phone

Cell Phone

Work Phone

E-mail Address

Driver's License Number

State

Expiration Date

Co-Owner/Authorized Person's Name

Emergency Contact

Cell

How Did You Hear About Us?

If referred by a friend, whom may we thank?

Horse’s Name

Date Of Birth

Sex

Breed

Color

Fill in these fields only if you have an additional horse

Horse’s Name

Date Of Birth

Sex

Breed

Stable Location / Address

Current Medications/allergies

Previous Veterinarian From whom Records May Be Requested

We love to share photos of our patients! Do you give us permission to share photos of your horse on social media?

YesNo

Color

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

Today’s Date

Name

Street Address

City

Zip Code

Home Phone

Work Phone

Cell Phone

E-mail Address

Date of Birth

Driver's License Number