Dear Potential Client,

Please be advised that in order to continue providing the best quality service and care possible, we are accepting new clients on a limited basis at this time. If you are interested in becoming an EVS client, please take the time to fill out this form carefully. Once we've had a chance to review your application, we will contact you to discuss your needs and options.

We always look for ways to improve our Practice. In an effort to be more efficient, we ask you to fill out this form for each animal you would like to register with us, and submit it before calling the office. Please provide as much information as possible, and notice that fields marked with a red star are required. All information submitted here will be treated as personal and confidential, and will be used only for professional purposes related to the care of your animal. Having this information in advance will help us to be better prepared to answer your questions and handle your account in a timely manner. It will also be very beneficial in the event of an emergency.

Equine Veterinary Service

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CLIENT INFORMATION:

 

 

*Client Name:

*Home Phone #:

Work Phone #:
Cell Phone #:
Best Phone#
*Address:

*City/State/Zip:

Email Address:
 
Stable Manager:

Stable Phone #:
Stable Name:
Stable Address:
Directions to stable from Route 26/100 in Cumberland:
Preferred method of payment:
*Previous Veterinarian:
*Previous Dental Care Provider:  
*Current Farrier:  
Would you like to receive our email Newsletter, Healthier Horses? Yes No

If you would like to specify a different email address for the newsletter, please do so here:
   

ANIMAL INFORMATION:
   

*Animal Type:

*Name:

Age:

Weight:

Gender:

Feed schedule:

Normal Temperature:

Normal Pulse:

Normal Respiratory Rate:

 

 
De-worming:  

Method, Frequency
 & Last Administration

 

  
   
   
Vaccinations:  

West Nile Virus:

Rhinopneumonitis:

Influenza:

E/W Enceph.:

Tetanus:

Rabies:

IM Strangles:

IN Strangles:

Potomac Horse Fever:

Other:

 

  

Medical History:

 

Current Medications:

Current Problem:

Previous Issues:

Injuries:

Illnesses:

   

General Comments:

 
 

Back To The Practice

Thomas A. Judd
 Equine Veterinary Services
 Cumberland, Maine
(207) 829-5885
 EMAIL

 
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