New Client Form Owner Name* First Last Owner Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Primary Phone*Other PhonePlease list the names of any other person that you give permission to authorize treatment and allow access to you horse(s) medical records. In some circumstances, this could include permission for euthanasia during a life threatening emergency.Name & PhoneHow did you hear about us? Please check one:*ReferralFacebookWebsiteBarn Name*Registered NameDOB*Gender, please check one:*GeldingStallionMareBreedColorMicrochip #Physical Location of AnimalPhysical Location different than Owner Address above?YesNoTrainer/Barn OwnerTrainer/Barn Owner PhoneInsurance InformationInsurance?YesNoFinancial PolicyAll invoices must be paid for at the time of service with the following payment options: - Payment due in full by cash, check, or credit card at the conclusion of your appointment, or at discharge. - We accept Visa, MasterCard, Discover or American Express. For those clients who cannot be present at the time of service, you can provide your credit card information, or you may leave a form of payment with your agent/barn owner/etc. - You may provide credit card information to the office to keep securely on file. Those choosing this method will have their credit cards charged and a receipt mailed to them. - A $40 returned check fee will be issued for all returned checks. - In the event that your horse is hospitalized, a deposit is required upon admission and the balance is due at time of discharge or case resolution. You will be required to sign a financial contract at the time of hospitalization.Photographic Release WaiverThere may be times when Edisto Equine Clinic's staff, the media, or other organizations, with the approval of Edisto Equine, may take photographs of patients or videotape patients. Those photographs and/or videotaped images (without patient identification information) may appear in veterinary medical publications, on the Edisto Equine website, on an Edisto Equine social media oulet, in the news media, or in other equine-related organizations' publications. I hereby grant Edisto Equine Clinic permission to use my equine's photograph and/or videotaped image for the purposes mentioned above.Full Name as SignatuureEmailThis field is for validation purposes and should be left unchanged.
