Veterinary New Client Enrollment Form

Welcome

Thank you for considering Motion Equine Veterinary Services for your animal healthcare needs. Please fill out our new client/patient registration form in entirety to ensure we can provide you and your animal with the best possible care.
Owner's Name*

First NameLast Name
E-mail*
Main Contact Number:*

Area CodePhone Number
Secondary Contact Number:

Area CodePhone Number
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is There a Spouse/Partner/Family Member Who Should Be Listed On Your Account?

YesNo
Spouse/Partner/Family Member Name

First NameLast Name
Please tell us how the above person is related to you so we can refer to your relationship appropriately.
Spouse/Partner/ Family Member Contact Number:

Area CodePhone Number
Is there anyone else (besides above listed contacts) who should be listed on your account, who has ongoing permission to make medical decisions for your animal (Usually this is a barn manager or trainer)

YesNo
Additional Contact:

First NameLast Name
Relationship
Contact Number

Area CodePhone Number
Additional Contact

First NameLast Name
Relationship
Contact Number

Area CodePhone Number
Please tell us who we may thank for your referral!

Client Policies and Procedures

We want you to be aware of and understand the following policies and procedures for all clients.
We Love Social Media! Do we have your permission to post pictures of your animal(s), you and your animal(s) and/or your animal(s) and our team on Facebook, Instagram, Twitter, www.motionequinevet.com and any other marketing and/or other social media outlets we may choose to use?*

YesNo
I agree to release Motion Equine Veterinary Services from all claims for libel, slander, invasion of privacy, infringement and copyright or right of publicity or any other claim and confirm that you are over the age of 18 years old. (initial below)*
Initial
Motion Equine Veterinary Services uses email and text for communications regarding our patient's reminders for health care needs. Do we have your permission to contact you via email and text regarding these reminders? *

YesNo
FINANCIAL POLICY:

Our office accepts e-transfer, Visa and Mastercard. We also accept cash and checks (only with verification of valid drivers license or other ID at time of payment).

Full payment is due at the time of receipt of month end statement. This includes any charges/fees agreed to by my authorized proxy. Our team is happy to provide any client with a written treatment plan prior to services being rendered.

going forward, in 2021 Clients will be responsible for a 1.5% monthly finance charge on accounts over 90 days and any collection and/or legal fees on accounts over 120 days. Your signature below indicates your agreement with these policies.
TREATMENT CONSENT:

By signing this document, I declare I am the lawful owner of all listed pets and all information is true and correct to the best of my knowledge. I hereby authorize the veterinarian(s) of Moion Equine Veterinary Services to examine, prescribe for or treat my animal(s) to the best of their abilities. I assume responsibility for all charges incurred in the care of this animal. I acknowledge that medical information will not be released to anyone not indicated on this form without my express verbal and/or written permission with the exception of another veterinary facility.
Clear
Should be Empty:

Welcome

Client Policies and Procedures