NEW CLIENT INTAKE FORM - EQUINE

Dr. Paige Mott D.C., Karma, and the staff at Discover Life Chiropractic welcome you and

your animal family members!

We are happy that you have entrusted our office with the care of your horse. To provide you with quality, timely care, we need your cooperation with certain matters to ensure every patient has his/her needs met.

PAYMENT:

Payment for services is due at the time of service. We accept cash, checks, MasterCard, Visa, Discover Card, and American Express. There is a $25 charge for any returned checks. Balances beyond 30 days will be charged an additional 1.5%. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, and any other expenses incurred in collecting your account.

CONTROL AND BEHAVIOR OF YOUR ANIMAL:

As the owner of your horse, it is your responsibility to remain in control of your horse at all times. This includes but is not limited to, restraining your horse, muzzling (when necessary) etc. Should your horse become out of control, you as the owner are responsible for any damages or injuries caused by your horse.

AUTHORIZATION:

> I authorize the staff to perform any necessary services needed during diagnosis and treatment.

> I authorize Dr. P. Paige Mott/Discover Life Chiropractic to release any information concerning my animal’s physical condition which may be deemed appropriate and necessary to my animal’s veterinary doctor for combined treatment of my horse.

This is the entire agreement between Discover Life Chiropractic and the client/owner below. I have read this agreement, understand it and agree with its provisions. I received a copy of it at the time of signing it below.