Owner Information

Owner First Name *

Owner Last Name *

Email *

Primary Phone *

Mobile Phone

Work Phone

Address *

City *

State *

Zip Code *

How did you hear about us? *

Primary Care Veterinarian

Internet

Friend / Family

Community Event

Signage

Printed Publication

Radio

Other

Do you have Insurance?

Emergency Contact

Primary Emergency Contact Name *

Primary Emergency Contact Phone *

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.

Secondary Emergency Contact *

Secondary Emergency Contact Phone *

Do you authorize your emergency contact(s) to make urgent treatment decisions if you are unreachable? *

Yes

Do you authorize your emergency contact(s) to receive patient information in addition to your primary care veterinarians? *

Yes

Patient Information

Barn Name *

Registered Name

Birth Date / Age *

Gender *

Breed

Color

Is the Physical Location different than Owner Address above?

Trainer / Barn Owner Name

Trainer / Barn Owner Phone

Financial Policy

All 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 Waiver

There 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.

Authorization

Digital Signature below authorizes treatment and is a guarantee of payment for all charges.

Digital Signature Authorization *

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New Patient Form for Horses

Option 1

Complete Online

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Complete on Arrival

New Horse Form