Wellness Sign-up Sheet Welcome to Wellness!Your name *Date *Your 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 SamoaYemenZambiaZimbabweCountryPhone *Email address (your payment verification will be emailed to this address) *Barn Name *Barn Address, if different than home 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 SamoaYemenZambiaZimbabweCountryContact name, if boarded Contact Person's phone if boarded Name of Horse #1 *Please choose a Wellness Plan for 1st horse: *Performance/ Under 3Weekend WarriorPasture PetImportant note: The Senior Add-on is not a stand-alone Plan. It must be added to one of the three Wellness Plans.Would you like the Senior Add-on? *YesNoName of Horse #2 (if applicable) Please choose a Wellness Plan for 2nd horse: Performance/ Under 3Weekend WarriorPasture PetWould you like the Senior Add-on? YesNoRun out of room? If you are putting more than two horses on Wellness, you may complete this form, and then call our office at (352) 472-1620 to complete your order.Payment Options Please choose one of the following payment plans:Upfront paymentMonthly installmentsTrip charges still apply! Please be aware that Wellness Plans do not include trip charges. We will charge your credit card on file at each visit for trip charges, additional medications, and other services, as applicable. If you bring your horse(s) to our Clinic for their Wellness appointments, then there is no trip charge!Payment Methods We accept the following forms of payment: ACH (Bank Draft) *preferred method! - Personal Check (upfront payment only) - All major credit cards/ debit cards.Credit Card Number Expiration Date CIC Security Code Monthly Installments: Monthly payments are made by credit card, or by ACH withdrawal from your checking/savings account, also known as a bank draft. You must also provide a valid secondary credit card, which will be billed in the event that there are insufficient funds in your bank account, or if your primary card is denied. You may choose to have your payment made on the 1st or the 15th of each month. If you choose monthly installments, please be sure to fill out the credit card information as well as the bank account information for ACH!For ACH Payment (bank draft), please select account type: CheckingSavingsBank Account Number: Routing Number: Monthly Installments Schedule: If you are making monthly installments, you may choose to have your payment run either the 1st or the 15th of each month:1st of the month15th of the monthAuthorization By submitting this form, you are authorizing Springhill Equine Veterinary Clinic to either charge your credit or debit card, or draft your bank account, as specified by your responses. You acknowledge that there are no refunds.IMPORTANT! There are no refunds, and plans are not transferable between horses. Any services not completed by the end of the calendar year are forfeited unless by the fault of Springhill Equine.IMPORTANT! If your horse(s) resides outside our emergency response range, which is not the same as our regular appointment range, you may be required to haul your horse to our Clinic for emergency treatment. Please confirm with our office staff whether you are inside or outside the emergency response range.Thank you! If you have any questions, need to add horses, change your order, or give us payment information, please call our office at (352) 472-1620.New Clients: If you are a new client and not yet in our system, please go to our home page after submitting this form and complete the New Client Form listed in the main menu. Thank you! VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>:
