Equine hospital and ambulatory service
About
Our Team
Facility
Services
Diagnostics
Preventative Medicine & Wellness Plans
Dentistry
Farrier Care
Pre-purchase Exams
Sports Medicine
Coggins & International Export
Ophthalmology
Alternative Therapy
Emergency Medicine
Reproduction
mare services
Stallion Services/Catalogue
Mare Prenatal Calculator
Foal Preventative Care Calculator
Products
Clients
Influential Equine Athlete Program
New Client Registration Form
Pre-purchase Exam Form
Coggins & Export Forms
Prescription refill request form
Upcoming events/seminars
Careers
Contact
Blog
☎ (780) 898-9267
Equine hospital and ambulatory service
About
Our Team
Facility
Services
Diagnostics
Preventative Medicine & Wellness Plans
Dentistry
Farrier Care
Pre-purchase Exams
Sports Medicine
Coggins & International Export
Ophthalmology
Alternative Therapy
Emergency Medicine
Reproduction
mare services
Stallion Services/Catalogue
Mare Prenatal Calculator
Foal Preventative Care Calculator
Products
Clients
Influential Equine Athlete Program
New Client Registration Form
Pre-purchase Exam Form
Coggins & Export Forms
Prescription refill request form
Upcoming events/seminars
Careers
Contact
Blog
☎ (780) 898-9267
New Client Registration Form
New Client Registration Form
CLIENT INFORMATION
Name
*
First Name
Last Name
Email
*
Home Phone
Cell Phone
Work Phone
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
Please note all invoices and statements will be sent by email.
PATIENT INFORMATION
Name
Breed/Color
Date of Birth
Gender
Mare
Gelding
Stallion
Discipline
Name
Breed/Color
Date of Birth
Gender
Mare
Gelding
Stallion
Discipline
Name
Breed/Color
Date of Birth
Gender
Mare
Gelding
Stallion
Discipline
Name
Breed/Color
Date of Birth
Gender
Mare
Gelding
Stallion
Discipline
Name
Breed/Color
Date of Birth
Gender
Mare
Gelding
Stallion
Discipline
INSURANCE INFORMATION
Insurance Company
Contact Number
BOARDING INFORMATION
Stable Name
Contact Number
TRAINER INFORMATION
Trainer's Name
Contact Number
I authorize that my trainer, as listed above, has authority to have Westhills Equine Veterinary Services provide veterinary care for the horses listed above. Please specify details associated with care below:
Please check all that apply:
Schedule appointments with a Veterinarian.
Request and pick up medications, feed, and supplies.
Discuss treatment plans and results with Veterinarian.
Discuss past and current history with Veterinarian.
Make treatment decisions on my behalf with Veterinarian.
Have treatments and supplies billed to my account.
PAYMENT POLICY
It is Westhills EVS’s policy that payment is due at time of service. We ask clients to inform the attending vet of their preferred method of payment at the time of service. Westhills EVS’s accepts payment by E-transfer, Cash, Visa, or Mastercard. In addition, Westhills EVS can process debit or Visa debit transactions at the Westhills EVS office, but debit and Visa debit cannot be accepted by phone or email. Westhills EVS will invoice clients by email or at the time of service. Please inform the clinic if you have not received an emailed invoice within a few days of your appointment. Westhills will notify the client of late or outstanding balances. If the balance remains unpaid it will be charged to the credit card authorized below unless prior arrangements have been made. Any unpaid balance will be charged interest after 30 days from the date of invoice. If Westhills EVS is not able to process an outstanding balance on the credit card authorized in this Registration From, and the balance remains unpaid 60 days after the date of invoice then it will be sent to Collections.
PREFERRED METHOD OF PAYMENT
*
Cash
Debit/Debit Visa (in clinic only)
E-transfer
Credit Card
CUSTOMER CONSENT
*
I allow and authorize Westhills Equine Veterinary Services to perform veterinary services and treatments on my animal(s). I agree to pay in full for all veterinary products and services rendered at completion or admission of my animal to the hospital. If I do not honor this agreement, I the undersigned, agree to pay 18% interest per annum. For any reason, if further action is required, I also agree to pay a 30% Collection Fee, any reasonable attorney fees and court fees.
I agree that by submitting this electronic form, that I am electronically signing the form and I, the undersigned declare that the information is true to the best of my knowledge.
E-Signature
*
Please type your name in order to electronically sign this form.
First Name
Last Name
Thank you!
