NEW CLIENT FORM | Elemental Veterinary

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Tel: 661-505-8840

NEW CLIENT FORM

Please fill out the following form so we can add your contact and horse information into our system.

Client Information

First Name

Last Name

Email

Phone

Select an Address

Preferred Method of Contact

Email

Text Message

Phone Call

Boarding Facility (if applicable)

Patient Information

Patient Name

Species

Age or Date of Birth

Gender

Breed

Color

Requested Services

Float/Balance

Core Vaccine (EEE, WEE, WNV, rabies, tetanus)

Rhino/flu Vaccine (EHV 1/4)

Patient Information

Patient Name

Species

Age or Date of Birth

Gender

Breed

Color

Requested Services

Float/Balance

Core Vaccine (EEE, WEE, WNV, rabies, tetanus)

Rhino/flu Vaccine (EHV 1/4)

Patient Information

Patient Name

Species

Age or Date of Birth

Gender

Breed

Color

Requested Services

Float/Balance

Core Vaccine (EEE, WEE, WNV, rabies, tetanus)

Rhino/flu Vaccine (EHV 1/4)

TREATMENT CONSENT: I hereby authorize the veterinarian to examine, prescribe for or treat the above described pet(s). I assume responsibility for all charges incurred in the care of this animal. I understand that payment is always due IN FULL at the time of service. I recognize that financial concerns should be discussed PRIOR to exam & treatment. Our staff is happy to provide estimates.

PHOTO CONSENT: We love social media! Do we have your permission to share your pet(s)’ image and story on social media, our website & other forms of related media? Your name and personal information will never be shared.

Float/Vaccine Clinic Clients Only

Clinic Location

Clinic Date (this is not a confirmation of your appointment, speak to your organizer for date confirmation)

Your Signature

Thank you for your submission. This is not a confirmation of appointment. Please contact us to confirm your appointment. If you are joining a float or vaccine clinic, confirm your spot with your barn/group organizer.

OUR SERVICE AREA

Opening Hours:

Mon - Fri: By Appointment Only

Emergency Services:

Case-by-case Only for Established Clients

CONTACT

Thanks for submitting!

© 2024 Elemental Veterinary Services

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