New Client Form
Client Information
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Horse Information
If you have multiple horses, please use the "Add Another Horse" Button to add all additional horses.
*
Billing Information:
Name on Card
*
First Name
Last Name
Credit Card Details
*
Check if same as client name above
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Credit card listed above can be used for: (please check all that apply)
*
This service (date of service below with signature).
Automatically charge any services (current and future) to this card.
An invoice will be sent to:
*
E-mail
USPS
Cardholder Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Payment Agreement
Please Initial and Sign
The undersigned understands that they must pay all accounts in full upon receipt of invoice.
*
I am the owner or the agent for the owner of the animal described above, and I have the authority to execute this consent. I hereby consent and authorize John R. Steele & Associates, Inc. to provide treatment. I have also been informed that there are certain risks and complications associated with any veterinary procedure. I further understand that during the course of these procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures and that support personnel may be used as deemed necessary by the veterinarian
*
Client Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client Signature
*
Continue
Continue
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