New Client Intake Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Farm Navigation Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
WV / VA potential clients only: CKSRVS can provide telemedicine services with an annual ON FARM visit to establish and maintain veterinary-client-patient relationship (VCPR). This option should only be utilized if you do not already have an opportunity to use a local veterinarian (ex: local large animal vets are not accepting new clients). All producers are encouraged to establish and maintain a VCPR with a local vet who is able to provide sick animal and emergency visits. By establishing yourself as a CKSRVS client, you are acknowledging (1) the limitations of telemedicine services, (2) that these services cannot be utilized if it has been more than a year since your VCPR visit. and (3) it is BEST to establish and maintain a relationship with a local veterinarian when possible.
I agree
All clients: I authorize Central Kentucky Small Ruminant Veterinary Services (CKSRVS) to treat my animal(s). I understand that payment is due at time of service and that a cost estimate can be provided prior to the appointment upon request. I authorize CKSRVS to contact me via text message and/or email regarding my appointment, services, and invoice.
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