Option 1

Complete Online

Complete and submit the online form below.

Option 2

Complete on Arrival

If you prefer, fill out the form when you get to our hospital.

New Patient Form

Owner Information

Owner First Name

Owner Last Name

Primary Phone

Address

City

State

Zip Code

How did you hear about us?

Social Media

Friend / Family

Event / Competition

Blog Post

Other

Barn Information

Barn Name

Barn Manager / Authorized Agent Name

Barn Manager / Authorized Agent Phone

Address

City

State

Zip Code

Farrier Information

Farrier Name

Farrier Phone

Emergency Contact

Primary Emergency Contact Name

Primary Emergency Contact Phone

Secondary Emergency Contact Name

Secondary Emergency Contact Phone

Do you authorize your emergency contact(s) to make urgent treatment decisions if you are unreachable?

Yes

Do you authorize your emergency contact(s) to receive patient information in addition to your primary care veterinarians?

Yes

Patient Information

Patient Name

Birth Date / Approximate Age

Breed

Color & Markings

Presenting problem, special needs, concerns

Documentation

Upload related documents here:

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By submitting this form, I hereby authorize Equine Surgery & Medicine to render medical care for my pet(s) as deemed necessary by the veterinarian.

I understand that no guarantee can be given to the outcome of treatments and take it as my responsibility to comprehend any risks involved. I agree to pay for the cost of all services to which I consent to by written or verbal estimate.

I understand that a deposit is required before diagnostics and treatments can be initiated and that payment in full is required prior to discharge of patient from Equine Surgery & Medicine.

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New Patient Form

Option 1

Complete Online

Option 2

Complete on Arrival

New Patient Form

Owner Information

Barn Information

Farrier Information

Emergency Contact

Patient Information

Documentation

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