New Client & Patient Registration Form

New Client & Patient Registration Form
Client Details:
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
How did you hear about us?*
Is there someone we can thank for a referral?
Where do your horses live?*

At my home.At another location from my home (we must have the full address please).
Address where horses live if other than your home

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have a Trainer?*

YesNo
If you have a trainer, please provide trainer's name and phone number.

First NameLast Name
Trainer's Phone Number
Please tell us about your horse(s):
Horse 1*

Barn NameRegistered Name
Horse 1*

BreedColor
Horse 1*

SexDOB / Age
What is this horse's job? What do you use him for

Horse 2

Barn NameRegistered Name
Horse 2

BreedColor
Horse 2

SexDOB / Age
What is this horse's job? What do you use him for?
Do you have other horses to list?

YesNo

Horse 3

Barn NameRegistered Name
Horse 3

BreedColor
Horse 3

SexDOB / Age
What is this horse's job? What do you use him for?
Do you have more horses to list?

YesNo
If you have more than 3 horses, please bring a list to your first appointment!

DE CILLO EQUINE FINANCIAL POLICY

To reduce confusion and misunderstanding between our dedicated team and loyal clients, we have adopted the following financial policies. If you have any questions regarding these policies, please contact our Office Manager at Accounting@decilloequine.com. We can only provide the best team, state of the art equipment, medication, and care by being paid at the time services are rendered. While circumstances arise from time to time, payment in full is expected at discharge and when the appointment is complete.

Payment Options

1. Payment is required at time of service:

Full payment is due at the time of service. De Cillo Equine Clinic does not provide payment plans. For your convenience we accept cash, checks, credit cards (i.e.; VISA, Mastercard, Discover and American Express), and Venmo (Venmo is not the same as cash and receives a surcharge). To cover the cost of processing a credit or charge card transaction, credit card payments will include a processing surcharge in an amount not to exceed the cost of processing the charge (charges vary by clients’ credit providers, but most are 3.5%). Surcharges do not apply to cash, debit cards, or checks.
Please Initial Here*

Powered by Jotform SignClear
- De Cillo Equine Clinic requires a valid credit or debit card to be kept on file for all accounts. After 14 days with no payment on balances, De Cillo Equine Clinic reserves the right to charge said card for balances with fees accrued for any declined payments.
  In the event that a check bounces, a $35 fee will be issued for returned checks. Following 2 returned checks from the same client, checks will no longer permitted from said client.
  Deposits ($300-$500 for regular urgent care, $1,000+ for specialty procedures/etc.) may be required for same day urgent or emergent services, as well as new account appointment booking. We require purchases of medication and Routine Vaccinations, Coggins, and Health Certificates be paid in advance.
2. Care Credit and Scratchpay

Care Credit and Scratchpay offer clients financing options. De Cillo Equine Clinic accepts both of these lenders. Both are subject to surcharges based on financing options.

3. Insurance

Clients that have insurance will pay at time of service, then submit the invoices to their provider. De Cillo Equine Clinic will not extend terms on insured animals.

4. Interest Charge on Late Payments

Any account balance over 15 days past due will be assessed a 10% Interest Fee. The fee is calculated at 10% of total balance due including fees and interest. Any account that is over 15 days with no minimum payment will incur interest at a rate of 10% monthly.

De Cillo Equine Clinic reserves the right to refuse service to any client who has an overdue account balance.
By signing below, I confirm that I have read the Financial Policy and agree to the terms.
Signature*

Powered by Jotform SignClear
Should be Empty: