New Client Application | Pedersen Equine Veterinary Services

NEW CLIENT REGISTRATION

First name

Last name

Phone

Street Address

City

Region/State/Province

Postal / Zip code

Is this also the location of the horses?

Emergency Contact Name & Number

Relationship to you

Trainer or Boarding Location if Different from Owner's Location

Patient Name

Insurance Company

Insurance Company Phone #

Trainer or Boarding Location Phone #

I agree that my trainer, as listed, is authorized to have Pedersen Equine Veterinary Services provide veterinary care for the horse(s) listed below up to:

Year of Birth

Breed/Color

Gender

Breed/Color

Gender

Customer Consent:
I agree to pay in full for all veterinary services at the time of treatment. Should I default on any such payments, I, the undersigned, agree to pay 18% interest per annum, and if further action is required, a 30% Collections Fee, any reasonable attorney fees and any court costs incurred. I understand that my appointment may be audio recorded for the purpose of medical record keeping, if I do not wish to be recorded I will advise the veterinarian prior to the start of my appointment. I agree that by submitting this application, I am electronically signing the application. I, the undersigned, solemnly declare that the information I have provided is true to the best of my knowledge.

Please write full name to consent to Customer Consent:

Thank you! We’ll be in touch.