2026 Equine Wellness Program Enrollment

2026 Equine Wellness Program Enrollment

"Leading Your Horse to a Healthy Future"
Thank you for enrolling your horse(s) in the Elkhorn Veterinary Clinic Equine Wellness Program. You are taking an important step in providing excellent preventive care to your horse at an affordable price to you. We look forward to being your partner in the health of your horse.

If you need assistance enrolling your horse(s) or would like more information, please contact our office at 262-723-2644 or email us at largeanimals@elkhornvet.com.
Client Name:*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Please list all horses you wish to enroll:*
Please make sure you have clicked "save" after your last entry and the number of horses listed is the same number as the number of horses your are enrolling.
I am enrolling*

1 or 2 horses3 or more horses
Total number of horses I am enrolling today:*
Total amount due to pay in full
Total amount due if paying 1/2 down
If you select to pay 1/2 down, your credit card will automatically be billed the remainder in 5 equal monthly credit card payments.
Please choose one:*

I would like to pay in fullI would like to pay 1/2 down and make automatic payments over the next five months.
Please charge my credit card on file.
Last 4 digits of credit card placed on file after 10/1/2022
I am choosing another form of payment:

Text me a link to pay in full.Call me for a current credit card to put on file.Check or cash.
In addition, I authorize the use of this credit card for the following:*

I authorize the use of this credit card to take advantage of the additional 10% discounts associated with the wellness program and recognize I will be billed at the time of service.I authorize the use of this credit card for all additional work done at the wellness program visit (i.e. call charge, Banamine injection, sheath cleaning, etc.) and recognize I will be billed at the time of service.I do not authorize the use of this credit card for any further purchases other than the purchase of the above wellness program(s). I understand that this disqualifies me from receiving the additional 10% discount on eligible services.
Signature*

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Date*

MonthDayYear
Date
Should be Empty: