Phone

This field is for validation purposes and should be left unchanged.

Client Name*

Phone*

Physical Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Reminders

Voice
Phone
Email
Text

Equine Information

Equine Name*

Breed*

Color*

DOB/Age*

Sex*

Male
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

Is your pet currently taking any medications?*

Yes
No

Please list previous surgeries or injections:

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

Yes
No

Do you have additional equines?*

Yes
No

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

Equine – New Client Form Financial Agreement

Equine Information

Equine Medical History

Accessibility Tools