New Client Customer Information and Payment Authorization

 

Please complete the form below—

** This form is required prior to your appointment so that Dr. Wolfrum Can provide the best possible treatment for your pet**

Owner Name *
Owner Name
Owner Phone Number *
Owner Phone Number
Owner Billing Address
Owner Billing Address
Trainer/Agent Name
Trainer/Agent Name
Trainer Phone Number
Trainer Phone Number
Primary Veterinarian Name *
Primary Veterinarian Name
Clients are required to have a valid Veterinarian-Client-Patient Relationshipi (VCPR) with their primary care veterinarian; this means that an exam must have been performed by your primary care veterinarian within the last year.
Primary Veterinarian Phone Number
Primary Veterinarian Phone Number
Please also include level of competition if applicable (ie 3' Hunter or Prix St George Dressage)
Patient Boarding Location
Patient Boarding Location
The Patient Boarding Location is where the pet resides (if separate from owner mailing address). Please include farm name and gate code if applicable as well as specific barn if it is a multi-farm property.
Please note that payment is due at time of service. Cash, personal check, or ACH payment (Zelle or Venmo) are preferred. If paying with credit card, please see description below for authorization of credit card payment.
Credit Card Payment Authorization
**PLEASE NOTE**Credit Card Number will be taken ONLY in person or over the phone and will be stored securely on the QuickBooksOnline encrypted server.