HHVS New Client Form / Update Information Form

PLEASE TAKE A FEW MOMENTS TO FILL OUT THIS FORM COMPLETELY. We will use this information to make sure your files and medical records are accurate and/or up to date. Thank you! -Highland Hill Veterinary Service

If you have questions: call/text 508-923-3422 or email info@highlandhillvet.com

Are you a new client? Or are you an established client updating your information?*

I am a new clientI am already a client with HHVS - I just need to update my information

OWNER NAME*

First NameLast Name

CELL PHONE (For Texts and Calls)*

EMAIL ADDRESS*

example@example.com

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Alternate Contact

NAME and PHONE NUMBER

IN CASE OF EMERGENCY CONTACT: If we are unable to reach you during an emergency - please list an emergency contact that you trust to make medical decisions for your horse/animal. *

NAME and PHONE NUMBER

NAME OF ANIMAL (Registered/Show Name and Nickname)*

TYPE OF ANIMAL*

HORSEOther

SEX*

MareGeldingStallionOther

BREED*

COLOR*

BIRTHDATE OR BIRTH YEAR OR AGE*

TATTOO / BRAND / REGISTRATION ID’S*

LOCATION OF HORSE*

Street Address

Farm Name

CityState / Province

Postal / Zip Code

FOR ADDITIONAL HORSES/ANIMALS: LIST NAME, SEX, BREED, COLOR, AGE, etc for each additional horse/animal.

I, the undersigned, hereby authorize Highland Hill Veterinary Service, LLC to perform veterinary service(s) on my animal(s). I understand that such treatment may include, but is not limited to, vaccination, medication, rectal palpation, digital imaging, dentistry, sedation/anesthesia, surgical procedures, and any other treatment that the doctor deems necessary for the health and safety of my animal(s).*

Agree

I, the undersigned, understand that I am financially responsible for the animal(s) I have requested services for.*

Agree

I, the undersigned, understand that payment is due at the time services are rendered. I understand that invoices over 30 days past due are subject to late fees. I understand that returned checks will be charged a returned check fee and future services can be denied. I understand that all accounts over 90 days past due are eligible to be submitted to our collection agency, American Profit Recovery. If your account is submitted to our collection agency we will no longer be able to provide services (emergency or routine) for you and your animals.*

Agree

I, the undersigned, would like to put a credit card on file with Highland Hill Veterinary Service. Please choose from the options below:*

Automatically charge my credit card on file after each visit and email me a receipt for services. I will call the office to give them my credit card information to keep securely on file.Keep my credit card on file but only use it with permission. We will email you an invoice and will expect to hear back from you with approval to charge the card we have on file. I will call the office to give them my credit card information to keep securely on file.I do not want to put a credit card on file.

I, the undersigned, am 18 years of age or older.*

Agree

I, the undersigned, allow Highland Hill Veterinary Service to text (SMS) my cell phone number. Message and data rates may apply. Message frequency varies. At any time you can text HELP for help or STOP to opt out. Information about our privacy policy can be found at www.highlandhillvet.com/privacy-policy.html*

Agree

SMS Privacy Policy: Highland Hill Veterinary Service, LLC may disclose Personal Data and other information as follows: Third Parties that Help Provide the Messaging Service: We will not share your opt-in to an SMS short code campaign with a third party for purposes unrelated to supporting you in connection with that campaign. We may share your Personal Data with third parties that help us provide the messaging service, including, but not limited to, platform providers, phone companies, and other vendors who assist us in the delivery of text messages. Additional Disclosures: Affiliates: We may disclose the Personal Data to our affiliates or subsidiaries; however, if we do so, their use and disclosure of your Personal Data will be subject to this Policy. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.*

Agree

SIGNATURE*

DATE OF SIGNATURE*

Date

HORSE / ANIMAL INFORMATION

AUTHORIZATION