New Client Registration - Equine Veterinary Dental Services

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 Country

Location*

Barn Hospital
Horse's Location

Stable Name*

Preferred Veterinarian*

Dr. Jeff Reiswig
Dr. Jason Dickey
Either Doctor

Horse's Name*

Gender*

Breed*

Color*

Age*

Horse's Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What Service Is Needed?

Preferred Days of the Week?*

How Did You Hear About Us?*

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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