Equine - New Client Information & Financial Agreement | High Prairie Veterinary Services

406-525-3878 HighPrairieVetOffice@gmail.com

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Equine –
New Client Information & Financial Agreement

Please complete the form below.

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Equine – New Client Information & Financial Agreement Form

Client Name *

First

Last

Cell Number *

Home Number

Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Email Address *

Reminders

Voice
Phone
Email
Text

Equine Information

Equine Name *

Breed *

Color *

DOB/Age *

Sex *

Mare
Stud
Gelding

Equine Medical History

Please complete to best of your knowledge

Indicate date of last vaccinations

West Nile

Tetanus

Rabies

East/West Encephalomyelitis

Rhinopneumonitis

Influenza

Fecal Float

Deworming

Dental Exam

Coggins

Does your equine show signs of illness or lameness today? *

Yes
No

If yes, please explain *

Is your pet currently taking any medications? *

Yes
No

If yes, please explain *

Please list previous surgeries or injections:

Has your pet had any previous reactions to anesthesia or sedation? *

Yes
No

If yes, please explain *

Do you have additional equines? *

Yes
No

Additional Equine Medical History

Please complete to best of your knowledge

Equine Name *

Breed *

Color *

DOB/Age *

Sex

Mare
Stud
Gelding

Indicate date of last vaccinations

West Nile

East/West Encephalomyelitis

Tetanus

Rabies

Rhinopneumonitis

Influenza

Fecal Float

Deworming

Dental Exam

Coggins

Does your equine show signs of illness or lameness today? *

Yes
No

If yes, please explain *

Please list previous surgeries or injections:

Has your pet had any previous reactions to anesthesia or sedation? *

Yes
No

If yes, please explain *

Equine Name

Breed

Color

DOB/Age

Sex

Mare
Stud
Gelding

Indicate date of last vaccinations

West Nile

East/West Encephalomyelitis

Tetanus

Rabies

Rhinopneumonitis

Influenza

Fecal Float

Deworming

Dental Exam

Coggins

Does your equine show signs of illness or lameness today?

Yes
No

If yes, please explain

Please list previous surgeries or injections:

Has your pet had any previous reactions to anesthesia or sedation?

Yes
No

If yes, please explain

Treatment & Financial Authorization-Please read and check off each statement below:

I verify I am the owner (or authorized agent for the owner) of the above-named equine. *

I verify I am the owner

I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that clinic personnel will be employed in the procedure(s) as directed by the veterinarian. High Prairie Veterinary Service (HPVS) will use all reasonable precautions against injury, death, or escape of my equine. *

I authorize the use of anesthesia and other medication

I accept the risk inherent in any anesthesia or surgery and release HPVS of any liability associated with the procedure. I further understand that there may be additional, deemed necessary, treatment or expenses upon further examination and commencement of my equine’s treatment plan. If my equine has fleas, ticks, mites, or internal parasites, Iunderstand that I will be charged with the cost of removing them. *

I accept the risk

I understand that my account must be paid in full within 30 days. *

I understand

I understand that if my account is unpaid there will be a finance charge of $5.00 or 10% (whichever is greater). This finance charge is automatically applied every month. *

I understand

I understand that should I default on payment of my account and collection agency services are required, all costs of collection up to 40% of the balance, including attorney/court costs will beadded to the balance of my account. *

I understand

I understand that if I am unable to pay for services or products in full at time of service, I must make prior arrangements to settle my account. Payment is due at time of service. *

I understand

Signature of Owner *

Clear Signature

Date *

We proudly serve the pets of Wolf Point and beyond.

Our philosophy is to provide excellent customer service and first rate pet care. We strive to create a relaxing-friendly environment for you and your pet. Our clinic is comfortable, pet-friendly, and calm.

CONTACT US!

Our veterinarians are highly trained in the treatment of any health condition. We’re a full-service mixed animal vet clinic with amenities designed to help you and your pet feel relaxed and at home in the company of our welcoming staff.

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Phone



email

HighPrairieVetOffice@gmail.com



address

420 Cascade Street
6182 Hwy 13 (mailing)
Wolf Point, MT 59201

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HOUR OF OPERATIONS

Monday – Thursday: 8am – 6pm
Friday: 8am – 5pm
Saturday – Sunday: Closed

We Can't Wait to Meet You!

Ready to schedule your next appointment? Visit out our online appointment request form by clicking below.

We are passionate about working together with you in the best interest of your pet.

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HAVE A QUESTION?

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please contact us if you have any questions or suggestions.

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