New Client FormOwner Name*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Please list the names of any other person that you give permission to authorize treatment and allow access to your horse(s) medical records. In some circumstances, this could include permission for euthanasia during a life threatening emergency.How did you hear about us? Please check one:ReferralFacebookWebsiteWho may we thank for referring you?Patient InformationBarn Name*Registered NameDOB Date Format: MM slash DD slash YYYY GenderGeldingStallionMareBreedColorMicrochip #Physical Location of AnimalPhysical Location different than Owner Address above?*YesNoAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Trainer/Barn OwnerTrainer/Barn Owner PhoneInsurance InformationInsurance?YesNoInsurance CompanyPolicy NumberPhone NumberContactSmarkpak ColiCare MemberYesNoIf yes, ColiCare Policy NumberFINANCIAL POLICYAll invoices must be paid for at 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, American Express and CareCredit. 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 on file through an electronically secure system. Those choosing this method will have their credit cards charged and a receipt emailed to them.A $30 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 time of hospitalization.Photographic Release WaiverThere may be times when Van Roekel & Associates, Inc’s staff, the media, or other organizations, with the approval of Van Roekel & Associates, Inc, 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 Van Roekel & Associates, Inc website, on a Van Roekel & Associates, Inc social media outlet, in the news media, or in other equine-related organizations’ publications.I hereby grant Van Roekel & Associates, Inc permission to use my horse's photograph and/or videotaped image for the purposes mentioned above.Signature below authorizes treatment and is a guarantee of payment for all charges.*CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
