New Client Form

New Client Form

Welcome to High Country Veterinary Services!
Name*

First NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Are you okay with text communications?*

YesNo
How did you learn about us?
SOCIAL MEDIA RELEASE (optional): From time to time, we take pictures to use on our website, social media, advertising, brochures, or educational presentations. We request your permission to take and use pictures of you, your animal(s), and any present family or guests for these purposes.*

Permission GrantedPermission Denied

Horse Name

Barn NameRegistered Name (if applicable)
Horse Age, Breed and Gender
Insurance Provider (if applicable)
Please note that if you do not provide us with your insurance information, this will delay any claims processes associated with your horse.
Insurance Policyholder Name (if applicable)
The name of the primary policyholder
Insurance Policy Number (if applicable)
The identifying number for your insurance policy
Horse Location:*

Owner AddressBoarding FacilityOther
Horse Physical Address

Facility Name

Street Address

CityState / Province

Postal / Zip Code
Does the property have a gate which requires an access code for entry? If so, please provide the code below.
Do you have any special instructions that might help us to find the location of your horse? Building colors and landmarks are helpful.
Has your horse been seen within the past year by another veterinary practice? If so, please include their information below so we may gather any prior records.

Clinic NamePhone Number or Email Address
Does your horse have any important medical history that our team should know about? Examples include accidents, illnesses, injury, surgeries, therapies, allergies or allergic reactions, etc.
Do you have a secondary contact who is authorized to initiate care and make medical decisions?

First and Last NamePhone Number

Payment Method on File

REQUIRED FOR ALL CLIENTS
Payment Due Upon Receipt. IF YOU DO NOT PAY ALL INVOICED CHARGES WHEN DUE, the invoiced charges together with, collection costs (including attorney fees) and late charges computed at $25 per month, and any other expenses involved in collection of the invoice (s) will be added. Invoices over 90 days past due will be sent to a Collections Agency.
Check the box to agree to keep payment method on file (This must be provided to clinic prior to your appointment)*

Credit/Debit Card, I authorize High Country Veterinary Services, LLC to keep my credit/debit card on file and to charge it for services, products, and pharmaceuticals rendered to me or my horse.
Agree to pay at time of service*

I authorize my payment method on file to be automatically charged at the time of service or will pay with cash or check at my appointment.
Signature*

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Treatment and Emergency Services Authorization:

1. I authorize the veterinarians and staff of High Country Veterinary Services, LLC, to perform examinations, give treatments, perform diagnostics and give prescriptions for non-urgent situations where I or my authorized agents have made an appointment for said animal, and have verbally given consent to treat during the appointment. I understand I am responsible for all costs incurred and will comply with High Country Veterinary Services, LLC’s financial and payment policies.

2. I authorize the veterinarians and staff of High Country Veterinary Services, LLC to examine my animal and perform necessary diagnostics and treatments in emergency situations were I cannot be reached. Our team will always make reasonable attempts to contact you by phone or in person, however, in certain circumstances where it is in the humane interest of the animal or patient, this may not be possible.

By signing below you authorize us to perform emergency services, which incur fees, on your animal, even in the event you cannot be contacted by phone or in person. In extremis, this includes euthanasia. Examples requiring immediate euthanasia would be a road traffic accident, severe and catestrophic colic that could not be transported to a referral center, broken bones that cause extreme pain, shock, and are non-recoverable.

Our emergency services guidelines and policies are on our website for your viewing. Emergency fees are associated with all urgent appointments, day and night, to off-set the costs of rescheduling other appointments during the day and providing emergency services after business hours, on weekends, and holidays. A current emergency fee schedule can be found on our website.

I understand I am responsible for all costs incurred and will comply with High Country Veterinary Services, LLC’s financial and payment policies.
e-Signature*

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New Client Form

Payment Method on File