• Image field 1

  • 3H Mobile Veterinary Services

    New Client Form

  • Client Information:

    Please provide your information below.
  • Format: (000) 000-0000.
  • Preferred Method of Contact:*
  • Format: (000) 000-0000.

  • Animal Location Information:

    Where your animals are located.
  • Are your animals housed at your home property? (circle one)*
  • Do I have your permission to share/release information about your horse's care with your trainer/barn manager?
  • Does your trainer or barn manager have your permission to make decisions about your horse's care, including costs?

  • Animal Information:

  • Date of Birth:*
     - -
  • Primary Use:*
  • Date of Last Veterinary Visit (if known):
     - -
  • Is your animal currently on any medications or supplements?*
  • Is your animal under the care of any other equine professional(s) (veterinarian, chiropractor, etc.)?*
  • Do I have your permission to share/release information about your animal's care with the individual(s) listed above?

  • Health History:

  • Is your animal up to date on core vaccinations (For horses this would include Rabies, Tetanus, West Nile, EEE/WEE)?*
  • Is your animal currently on a deworming schedule (to include heartworm prevention for small animals)?*
  • Do you have any additional animals to add?*

  • Payment Information:

  • Payment Preference(s)*
  • Is your billing address the same as your home address?*

  • Optional Questions:

  • 1. Are you interested in hearing about alternative therapy options for your horse(s), such as acupuncture and herbal supplements?
  • 2. How did you hear about 3H Mobile Vet?

  • Consent & Acknowledgment:

  • By signing below, you agree to the following (continued on next page):

    • To your knowledge, the information you have provided above is true and accurate and you are the owner or agent of the horse(s) listed above.
    • In your absence or in the event that you are not reachable during an emergency for your horse(s), you authorize the following individual to act as your Agent to make medical decisions for your horse.
  • Format: (000) 000-0000.
    • You authorize for your horse to be vaccinated for Rabies (at owner's expense) if they have not been vaccinated within the last year. Proof of current vaccination status or vaccine titers must be provided, otherwise we have the right to refuse service. Please provide documentation if prior vaccine reaction has been managed by a veterinarian.
    • You acknowledge that you are responsible for any fees associated with services rendered at time of service and/or upon receipt of invoice, unless prior arrangements are made with Dr. Emily.
    • You acknowledge that if payment is not received within 60 days, there will be a 1.5% compounded interest rate per month, or the maximum allowed by law, on unpaid balances to your account and your account will be considered "Inactive." After 6-months of non-payment, unpaid balances will be sent to a collection service.
    • I authorize Dr. Emily Hughes and 3H Mobile Veterinary Services (the "Practice") to perform procedures on my animal(s), including anesthesia and sedation, as well as, performing necessary veterinary treatments (such as vaccine administration). I have had the opportunity to ask questions and those questions have been answered to my satisfaction. The nature of such services has been described to me to my satisfaction and I realize that no guarantee can be made regarding the results or cure. I understand there are inherent risks with anesthesia, sedation and other medical procedures, including death. I consent to the risks associated with services provided by the Practice. I authorize the Practice and its staff, in an emergency situation, to perform procedures that arenecessary for the well-being of my animal on a continuing basis until further communication with me. I assume financial responsibility for all services rendered. The undersigned, if not the Client/Owner noted above, presents and warrants that he/she is signing on behalf of and with full authority to legally bind Client/Owner.
    • WARNING UNDER TEXAS LAW (CHAPTER 87, CIVIL PRACTICE AND REMEDIES CODE), A FARM ANIMAL PROFESSIONAL IS NOT LIABLE FOR AN INJURY TO OR THE DEATH OF A PARTICIPANT IN FARM ANIMAL ACTIVITIES RESULTING FROM THE INHERENT RISKS OF FARM ANIMAL ACTIVITIES.
  • Date:*
     - -
  •  
  • Should be Empty: