New Client / Patient Information & Consent Form

New Client / Patient Information & Consent Form

Please complete this form to provide your information, authorize treatment, and acknowledge consent and agreements as required.
Owner Name*
Phone*
Address*

Street Address

Street Address Line 2 (Apt, Unit, etc.)
CityState / ProvincePostal / Zip Code
Email Address*
Person Responsible for Payment*
Horse #1 (Full Name, Age, Breed, Gender)*
Horse #2 (Full Name, Age, Breed, Gender)
Horse #3 (Full Name, Age, Breed, Gender)
Horse #4 (Full Name, Age, Breed, Gender)
I authorize the Credit Card I have provided on the Credit Card Authorization Form to be kept on file to be used for payment of future invoices as indicated below (choose one):*

AUTO BILL: Run my credit card and send me a paid detailed invoice receipt.CREDIT CARD APPROVAL: We will call or email prior to running card, alternate form of payment can be provided within 7 days, otherwise the card will be run.
TREATMENT AUTHORIZATION: I am 18 years of age or older and do hereby authorize the veterinarians and technicians to examine and administer treatment as is considered necessary for my animal’s condition. An estimate of care options will be discussed prior to any treatments. In life threatening situations, stabilizing care may be instituted upon arrival. I understand that Chesapeake Equine Performance LLC may refuse services for any reason.*
PAYMENT AGREEMENT: The undersigned agrees that they are financially responsible for all services rendered at the time of service. Further, that in the event of default in payment after 30 days, the undersigned agrees to pay all costs of collection including reasonable attorney fees and court costs.*
NO OUTCOMES GUARANTEED: Client acknowledges that the risks and conditions of treatment to be performed have been explained and that there are no guaranteed outcomes with treatment.*
LIABILITY RELEASE, WAIVER, AND DISCHARGE: Client expressly understands that Chesapeake Equine Performance LLC veterinarians, its technicians, employees, and agents have agreed to provide their professional services based upon Client's agreement as follows: Client does hereby release, waive and discharge Chesapeake Equine Performance, LLC, and its veterinarians, technicians, employees, and agents from Liability for any and all claims, to the greatest extent allowed by the laws of the State of Maryland, for the veterinary services performed. Client understands and agrees that by signing this form, Client is forgoing substantial rights, including the right to sue Chesapeake Equine Performance, LLC, and its veterinarians, technicians, employees, and agents for damages arising out of the provision of their professional services. Client further understands and agrees to hold harmless, defend, and indemnify Chesapeake Equine Performance, LLC, and its veterinarians, technicians, employees, and agents from any and all claims made by Client.*
FINANCIAL RESPONSIBILITY: All charges are due at the time of service. A 1.5% monthly service charge or minimum of $25.00, whichever is greater, is applied to all balances over 30 days. Clients with accounts past due must pay previous balance in total prior to receiving additional services.*
NO SOLICITATION: Client acknowledges that Client was not solicited in any way by Chesapeake Equine Performance LLC veterinarians, their technicians, employees, or agents to provide veterinary services and sought out the services provided of their own accord.*
ELECTRONIC SIGNATURE AUTHORIZATION: I agree and consent to use electronic signatures, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement. If I do not initial this Authorization, then I understand I must remit this form with my handwritten signature.*
OWNER SIGNATURE: By typing my name below, I agree that this serves as my legal electronic signature.*
Date

MonthDayYear
If Multiple Owners or Leasers Please List Here
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