New Client Form - Springhill Equine Veterinary Clinic*Important Note Before you begin this form, please take a picture of your Driver's License or State-issued ID card. You will need to upload it at the end of the form. Client InformationDate *First and Last Name *Mailing Address *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryBarn Address *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryDirections from Newberry: *GPS doesn't always get us to you! Please give specific directions from the nearest major road coming from Newberry, FLGate Code *Enter N/A if no gate codeCell Phone *May we text you things such as upcoming appointment reminders? We will never send you any mass/group texts or sales texts. This function is only to better communicate with you about your appointments and prescriptions.YesNoHome Phone Email *Trainer/Agent Name Trainer/Agent Phone Is Patient Insured? YesNoIf Yes, name of insurance company Photo Release *May we use pictures of your animals on our website and social media platforms, or in educational slides and posters for our seminars and other promotions?YesNoHow did you hear about us? Referred by a friendGoogle searchFacebook postReferred by UF Veterinary SchoolReferred by another veterinarianEquestrian eventOtherIf referred by a friend, who can we thank with a referral bonus? Patient InformationPatient Species *HorseDonkeyOtherPatients Full Name/ Registered Name *Nickname Weight Age Breed Sex MareStallionGeldingColor/Markings Date of last Coggins Date of last West Nile Vaccine Date of last EWTR Vaccine Date of last Rabies Vaccine Date of last de-worming Date of last Flu Vaccine 2nd Patient InformationPatient Species HorseDonkeyOtherPatients Full Name/ Registered Name Nickname Weight Age Breed Sex MareStallionGeldingColor/Markings Are the vaccination dates the same as Patient 1? YesNoIf No, please list dates As the owner/agent for the above named animal(s), I authorize Springhill Equine Veterinary Clinic and their agents to treat this animal as they deem necessary. I assume responsibility for all charges incurred during the care of this animal. Please type name below as Authorized Signature * Payment InformationNOTE: Payment is due at the time services are rendered. Please choose a payment option *Charge my card after each visit.Pay by cash, check or money order at time of appointmentCard Type VisaMastercardAmerican ExpressDiscoverCareCreditCard Number Name on Card Expiration Date CVC Driver License Number *Driver License State *DL Expiration Date *Upload photo of Driver's License All personal and credit card information is held in strict confidence, and will never be shared with a third party. CommunicationHow do you prefer to hear from us? *We will give you an appointment reminder and any other necessary communications via your preferred method.Phone call on Home PhonePhone call on Cell PhoneTextEmailCall or text, I'm good either way! Please enter any two digits *Example: 12This box is for spam protection - please leave it blank:
