Equine New Client Information

Date

Steve VanWagner, DVM, MS Kim VanWagner, DVM

455 Hwy 150, New Waverly, Texas 77358

Welcome, we are glad you are here!!

New Client Information

Name

First NameLast Name

Salutation:

Mailing Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Physical Address (if different from mailing address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone

Work Phone

Cell Phone

Preferred Contact Number

Home PhoneWork PhoneCell Phone

Driver License #

Email Address:

Needed for coggins - example@example.com

Occupation:

Employer:

Emergency Contact

Emergency Phone

How did you first hear of Veterinary Hospital of New Waverly?

Phone BookDrove by ClinicPersonal Referral

Who Referred you?

Horse Information

Horse's Name:

Age:

Birthdate:

Sex

MareGeldingStud

Breed:

Color:

Barn/Stable Address (needed for coggins)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Which brand of horse feed do you feed? How much? Frequency?

Reason for this visit today:

Last date of deworming:

Brand/Type used

Last Date of Vaccinations:

VEWT

West Nile

Flu/Rhino

Strangles

Rabies

Coggins

Teeth Floating

Please list any history of surgeries and dates:

I hereby authorize the veterinarian to examine, prescribe for or treat the above described pet. I assume responsibility for all charges incurred in the care of the animal. I also understand that ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. Acceptable Methods of Payment are: CASH, CHECK, CREDIT CARDS (AMEX, DISCOVER, VISA, MASTERCARD), CARE CREDIT.

Signature of client responsible for horse(s)*

I grant full permission to Veterinary Hospital of New Waverly to use any and all images taken of me or of my pets for the sole use of education, advertising, and promotion. This includes but is not limited to photographic prints and products, cds, dvds, Facebook page, Twitter, You Tube videos, and other social media sites, website blogs, and website display. I certify that I am eighteen (18) years of age or older. I understand that a parent or guardian must complete this form when grating a photo release involving a minor child(ren).

Signature of client

Photo Releases