We welcome all new dental clients!Please complete the following form to establish your new account. If you have not already set up an appointment, be sure to include the questions about scheduling. Thank you! Name* Primary Phone #*Type Of Number*Cell PhoneLandlineWork PhoneSecondary Phone #Type Of NumberCell PhoneLandlineWork PhoneEmail* Preferred Method Of Contact* Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Horses (Please click the plus sign to add more than 1 horse)*NameGenderBreedColorAgeBarn NameRegistered Name Add RemoveHorse's Stable Location Same as owner address Stable Name Stable Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you working with a trainer?* Yes No Trainer's Name What Service Is Needed?HiddenPreferred Days of the Week? Monday Morning Monday Afternoon Tuesday Morning Tuesday Afternoon Thursday Morning Thursday Afternoon Friday Morning Friday Afternoon Saturday Morning Any Time How did you learn about our service?* Veterinarian Farrier Friend Boarding Stable Facebook Google search Website Group demonstration Other Veterinarian Name* Farrier Name* Friend Name* All payment is expected at the time of service. Accepting: Cash Check Credit Card (MC, VISA, AMEX, DISC) Paypal (link on home page) CareCredit 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 24% 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!I understand* I understand and acknowledge the statement above PhoneThis field is for validation purposes and should be left unchanged.
Equine Veterinary Dental Services