New Client Form

Vet Intake Form

Owner Information

First Name

Last Name

Address

Address Line

City

State

Zip Code

Phone Number

Barn Information

Barn Name

Barn Address

Address Line

City

State

Zip Code

Horse Information

How many horses would you like to input?

Horse #1 Name

Age

Gender

Breed

Color

Name of Last Dewormer

Date of Last Dewormer

Date of Last Dental Exam

Date of Last Coggins

Vaccines Given Within Last Year

Name of Vaccine	Date Given

Horse #1 Medical History:

Choose File

Horse #2 Name

Age

Breed

Color

Name of Last Dewormer

Date of Last Dewormer

Date of Last Dental Exam

Date of Last Coggins

Vaccines Given Within Last Year

Name of Vaccine	Date Given

Horse #2 Medical History:

Choose File

Horse #3 Name

Age

Breed

Color

Name of Last Dewormer

Date of Last Dewormer

Date of Last Dental Exam

Date of Last Coggins

Vaccines Given Within Last Year

Name of Vaccine	Date Given

Horse #3 Medical History:

Choose File

Billing

How will you pay for your first appointment?

Credit card (office will call for information)

Check or cash at appointment

Paypal

By default, digital copies of your monthly statements will be emailed to you. Do you consent to digital receipt of your monthly statements?

Yes, I would like my statements emailed to me.

No, I'd like to opt out. I prefer hardcopies to be mailed to my address.

Terms & Conditions

Terms and Conditions of Service

I hearby authorize Megan Snyder, VMD to provide veterinary care to my horse(s) in my abscence. *

I understand that payment for veterinary services is due in full upon receipt of our monthly bill. Overdue balances are subject to a 1.5% per month service charge and/or a minimum rebilling fee. Accounts with balances that are 90 days overdue are subject to a payment plan with established minimum payments and a credit limit.

I agree that I am currently able to comply with the payment requirements, but if I should become unable to make payment upon receipt of the monthly invoice, I will contact the office to discuss other arrangements for payment. *

I understand that there is a $25.00 charge for returned checks.

I understand there will be a $25.00 fee for all cancellations made less than 24 hours prior to the appointment time.

I understand a credit card will be kept on file for any balance that is not paid - within 30 days of service

Should Megan Snyder, VMD, be forced to initiate administrative and/or legal action to collect unpaid invoices from me, I consent to service of process by means of nationally recognized carrier with respect to any such claim by delivery of summons and complaint to the addresslisted on this form. Any legal proceedingsshall occur in Howard County, Maryland

Authorized Signature

Sign Here

Reason for Appointment

What is the reason for the appointment?