Owner Information

Owner's Name*

Owner's Primary Phone Number*

Email*

Billing Address*

Street Address Address Line 2 City State ZIP Code

Animal Address (if different from billing address)

Street Address Address Line 2 City State ZIP Code

Animal Name(s)*

Permission to treat all animals in your care*

Yes
No

How did you hear about our practice? Please choose all that apply

Advertising
Friend
Trainer/Barn
Veterinarian
Social Media
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Animal Information

Animal Name

Breed

Age or Date of Birth

Sex

Color

Current Medications

Animal Information 2

Animal Name

Breed

Age or Date of Birth

Sex

Color

Current Medications

Animal Information 3

Animal Name

Breed

Age or Date of Birth

Sex

Color

Current Medications

Agreement of Services and Authorization

I am the owner (or legal agent for the owner) of the animal(s) described above, and I have the authority to execute this consent.

I voluntarily give permission and consent for my animal(s) (described above) to be treated by Dr. Megan Knoell, Knoellwood Equine, and any of its associates, technicians, assistants or agents.

I understand that (in order to achieve a proper diagnosis and treatment plan) it is my responsibility to disclose any and all previous medical history (including lab results and radiographs when necessary) for my animal(s).

I understand that integrative treatments (including but not limited to acupuncture, spinal manipulation/chiropractic, herbal therapies) are regarded as generally safe and without many adverse effects. The nature and purpose of the procedures and treatment methods, risks involved and/or possibility of complications have been fully explained to me.

I understand results cannot be guaranteed, and that complications are inherent to some degree in any veterinary medical treatment, and cannot be predicted. I acknowledge that in the event of a complication or adverse reaction, I am not relieved of any obligation to costs incurred regarding my animal(s).

I understand that refills of prescription medications and supplements require one week notice (two weeks for compounded or custom made blends). Knoellwood Equine will not assume responsibility or liability for use or misuse of medications, herbal formulas or supplements obtained outside this practice.

I understand that Knoellwood Equine does offer emergency services for established clients, but it is a solo doctor practice that covers a large service area. Due to this, I may need to seek urgent or emergency care for my animal(s) outside of this practice. I have been informed of the emergency and referral practices in/around my area, and assume responsibility for arranging care and/or transportation in the event

I assume all financial responsibility for services rendered, and agree to pay in full at the time of service. A valid credit card is required on file (see "Credit Card Authorization Form") and will be charged for the full account balance if my account is more than 30 days past due. Balances unpaid after 30 days are subject to a monthly service charge. Accepted payments include cash, check, Venmo, Care Credit and major credit/debit cards.

This authorization agreement shall remain in effect until such cancelled in writing, or such a time when a different written agreement is executed.

Your Signature*

Date*

Comments

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