Forward Thinking Equine Veterinary Services

Client Information and Authorization Form

Please complete the form below and press the SUBMIT button. We will call you upon receipt to gather any additional information. Fields marked with * are required.
If you prefer to print this form, complete by hand and submit a hardcopy, click HERE to download it in Acrobat PDF format.

NOTE: While our site uses technologies to protect your data, as an added layer of protection for your most sensitive information, we do not collect required credit card and driver's license information on this form. We will call you upon receipt of this form to collect that information from you.

Client (Owner's) Full Name*

Email Address*

Street (Mailing) Address*

City*

State*

Zip Code*

Owner's Phone*

Additional Contact

Phone

Emergency Contact

Phone

Permanent Address (if different from Mailing)

City

State

Zip Code

Referred to Us By

Horse Registered Name*

Horse Barn / Alternative Name*

Breed*

Color*

Microchip?

Tattoo/Brand?

Date of Birth / Age*

Sex?*

Horse's Profession*

Insured*

Insurance Company

Policy Number

Trainer

Trainer Phone

Barn Manager

Barn Manager Phone

Name of Stable*

Stable Address*

Gate Code

Is Your Barn Manager Authorized to Call on Your Behalf?

Check here to agree to receive text messages from us. We will not share or sell any information that you provide to us.

Forward Thinking Equine Veterinary Services Payment Policy

All fees are due at the time of services rendered. We require all clients to have a credit card on file with us. We accept cash, check or credit card payment. For clients electing to pay by cash or check at the time of service, a 3% discount will be applied to their invoice. For clients electing to pay by credit card, invoices will be sent first via email, then we will debit the invoice and/or balance with your credit card on file. The balance on any past due account will automatically be charged to the credit card we have on file if we do not hear back from you within 60 days. Balances over 30 days will incur 1.5% interest charge monthly. Any NSF payment will incur a fee of $25. In addition, in the event of default where it becomes necessary to place this account into collections, you agree to pay all costs of collections, including attorney's fees and court costs.

All professional fees, medications dispensed, or mailed, are to be paid at the time of services rendered, all special order medications must be paid at the time of ordering.

Our Practice

Services

Contact

Forward Thinking Equine Veterinary Services, PC

P.O Box 48 Green Lane, Pa 18054

Phone: 610-851-4282

Hours: By appointment

office@forwardthinkingequine.com