New Client Form | Canopy Equine

Owner's First Name

Owner's Last Name

Other Important Contact (Barn Manager, Trainer, etc.) Please provide their full name and contact information.

Email

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

If we need to visit your farm, please give name, address, and phone number of stable manager. *Please include gate code, if applicable.*

Horse's Name (Registers & Barn Name)

Age (Estimate or D.O.B)

Breed

Color

Sex

Stallion

Gelding

Mare

Brief History

Reason for Visit

We are now seeing clients at our new clinic in Reddick, FL. Haul-in appointments can typically be scheduled sooner than farm visits. Please let us know if you are able to trailer your horse to the clinic, or if a farm call will be required.

Yes, I can haul my horse to your clinic in Reddick.

No, I need a farm visit.

Is your horse insured?

Yes

No

Please provide the name and number of your established veterinarian.

Please provide the name and number of your regular farrier.

Alerts/Behaviors

Do you have recent radiographs?

Yes, I do. I will email them to info@canopyequine.com.

No, I do not have radiographs.

Do you have recent bloodwork?

Yes, I do. I will email them to info@canopyequine.com.

No, I do not have bloodwork.

I understand that payment is due at the time of service. I understand that my card number will be tokenized for my protection, and the actual number will not be stored by Canopy Equine for security purposes.

Cardholder's Name (As it appears on the card)

Credit Card Number

Expiration Month

Expiration Year

CVV

Cardholder's Zip Code

I authorize that this form is complete in it's entirety and as the owner/agent for the animal(s) listed above, I authorize Canopy Equine Veterinary and Podiatry and their agents to treat this animal as they deem necessary. I assume responsibility for all charges incurred during the care of this animal.

Signature

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CANOPY EQUINE
VETERINARY AND PODIATRY

New Client Intake Form

Please fill out the form below. Our office will contact you within 48 hours to schedule an appointment.