SEVS New Patient Registration

SEVS New Patient Registration
Compassion. Community. Quality Care.

Thank you for entrusting SEVS to care for your equine partner!
Owner Information:
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Yes.No, please fill out Page 3 of this form.

Patient Information:
Name:*
Barn Name
Registered Name:
If Applicable
Breed:*
Color:*
Age/DOB:*
Sex:*
Please list any current medications your animal is taking:*
If on no medications currently please type "None" in the field above
YesNo

Patient's Location/ Trainer/ Barn Information
Farm or Stable Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Trainer or Farm Manager Name:
Phone Number:
Point of contact for stabled location.Format: (000) 000-0000.
Email:
Please list name and contact of those authorized to consent to treatment if you cannot be contacted:*
If no other individuals have authorized consent for treatment, please type "None" in the field above.

ALMOST FINISHED!

We kindly request that payments be made at the time of service. If you are unable to be present for an appointment a credit card on file is required prior to your scheduled appointment. If payment arrangements have not been made prior to a scheduled visit services will not be rendered.

We accept cash, check, all major credit cards, and Care Credit.
YesNo, I will be present for appointments to pay at time of service
By signing I agree that I have read and understand the above statements and agree to all terms therin.
Signature*

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Date*

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Date
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