Existing Client Update Form

Existing Client Information Update Form:

Thank you for choosing High Country Veterinary Services to care for your equine partners! Please complete the following form:

Client Name*

Phone Number*

Email*

example@example.com

Is anyone else allowed to make medical decisions for your animal(s)? If so, please include their full name and phone number below:

Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code

Horse Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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.

Treatment and Emergency Services Authorization For Patients on Your Account (REQUIRED):*

Signature*

Today's Date*

Date

We require a payment method be on file for all clients. Please agree to the following:*

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.

2 Choose your preferred payment timing

I agree to pay all invoices upon receipt. In the event that an invoice is not paid within 30 days of the invoice date, I understand my payment method on file will be charged.I authorize my payment method on file to be automatically charged within 24-48 hours of invoice creation.THIS FIELD IS HIDDEN SO WE DONT LOSE ANY DATA

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.

I confirm and agree to pay for all veterinary fees related to the care of said animal(s) on my account to High Country Veterinary Services, LLC.

Signature*

Today's Date*

Date