Cave Creek Equine Client Consent Owner Information Full Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d’IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Primary Phone Phone Fax Email Spouse / Co-Owner Name Spouse / Co-Owner Phone Patient Information Registered Horse Name Species Breed Sex Age Color Referring Veterinarian Trainer Trainer Phone Facility / Barn Name Procedure Requested Location Right Front Left Front Right Rear Left Rear Head Rump N/A Date of Most Recent Tetanus Shot What type of hay does your horse eat? Financial Information Payment in full is required at the completion of services. Final payment may be made by credit card, cash or check. Please note all returned checks will be charged a $35 fee. If the account is NOT paid in full at the completion of services, and after you review of the final bill, the amount due will be charged to your credit card. This page is unsecured. Do not enter a real credit card number! Use this field only for testing purposes. Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name There is a cancellation fee for no shows and appointments that cancel with less than 24hrs notice. Client Authorization Client Authorization I hereby authorize the veterinarian at CCESC and their assistants to examine and/or perform the necessary procedures. If any unforeseen condition arises in the course of the operation, calling for their judgment for any procedure in addition to or different from those now contemplated, I further authorize them to do whatever is necessary to avoid any unnecessary suffering by the animal (including euthanasia). I acknowledge that no guarantee has been made as to the results that may be obtained. This facility is not staffed 24 hours. Patient Insurance The insurance carrier for animals is handled differently than the medical insurance carried for yourself. We are not reimbursed by the insurance companies for services rendered. Cave Creek Equine will be happy to assist in completing the required insurance paperwork for your reimbursement once the account has been paid in full. Discharge: If you are not present at the time of discharge, your completed invoice will be faxed or mailed to you and payment will be charged to the credit card you have indicated on your admission form. A copy of the receipt and your final bill will be mailed to you. Submission How did you hear about us?FriendAdvertisingWebsiteSocial Media Date Signature(if you are printing this form) Client Agreement I have read and understand the above stipulations. By checking this box I agree with the above. I have read and understand the above stipulations. By checking this box I agree with the above. This iframe contains the logic required to handle Ajax powered Gravity Forms. or print this form: Download PDF
