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 *

Email *

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 *

Vaccination Status *

Gender *

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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