REVS New Client Form

REVS Rehab Consult
Client Information*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of regular veterinarian*
Please provide name of DVM or practice.
Patient Information (Single)*

Patient NameAge/ Breed/Sex/Colour
Please select ONE of our 2 invoicing options:*

Invoices delivered by email with monthly statement (please check spam folder often)Auto Pay: Invoices are delivered by email and credit card will be charged automatically at the end of the month, followed by a statement which will display payment. If this option is selected, the office will contact you to gather credit card information
Please email all of the following to sportsmedvet@gmail.com:
- Pertinent veterinary medical records, including definitive diagnosis
- Veterinary imaging, ex: radiographs and/or ultrasound
- Shorts videos, trotting on lunge line, left and right circles
- Conformation photos (from the front, from behind, left side and right side)
Should be Empty:

REVS Rehab Consult