Touchless payment options: You may pay online via Paypal, or by credit card over the phone. Please contact us today if you have any questions!

New Client Registration

We welcome all new dental clients!
Please complete the following form to request an appointment. Please also note that availability will vary depending on your request. We will contact you by email or phone to establish your appointment date and time.
Name*
Phone*
Email*
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Horses*
Name Gender Breed Color Age
Horse's Address
- Same as owner address
Stable Name and/or Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
What Service Is Needed?
Preferred Days of the Week?*
- Monday Morning
- Monday Afternoon
- Tuesday Morning
- Tuesday Afternoon
- Wednesday Morning
- Wednesday Afternoon
- Thursday Morning
- Thursday Afternoon
- Friday Morning
- Friday Afternoon
- Saturday Morning
- Any Time
How Did You Hear About Us?*
Which method of payment do you prefer?*
- Payment by check or cash at time of service
- Call with Credit Card info before appointment
- Use Paypal tab on website
All payment is expected at the time of service.
Accepting cash, check and credit card (VISA, Mastercard, Discover & American Express)
Your prompt payment is valuable to this practice to maintain the highest professional level of services at affordable prices. Any charges not paid at time of service may be assessed a finance charge at an annual rate of 18% plus billing fees. Client agrees that if the account should become past due or delinquent, the client will pay all expenses of collection of the account, including but not limited to collection fees, attorney fees, filing fees, court costs and interest.
Thank you for your cooperation in this matter!
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Name	Gender	Breed	Color	Age