New Client Form, University of Minnesota Equine Clinical Services

EQUINE CLINICAL SERVICES
University of Minnesota College of Veterinary Medicine

NEW CLIENT PRE-ADMISSION FORM

Welcome to the Equine Clinical Services . Please complete as much of the information requested below as possible and return the form electronically, ("Submit" at the bottom of the form) or fax (612-625-9796) before your scheduled appointment.  If you cannot return the form before your appointment, please complete and print the form and bring it with you. (Click HERE for a printable form) A helpful check list is provided.  Thank you and we look forward to your visit!

NEW CLIENT INFORMATION

A.  Owner Information

1. Owner Name: Last First: MI:
2. Owner Address: (more)  
  City: State: ZIP:
3. Phone Numbers: Home Work Cell
  Barn Other
4. Other Contact Information Fax Email

B. Agent Information:

If an individual is serving in the role of an agent, we require the following information. An agent is an individual who has been given permission by the owner to make decisions about the evaluation and treatment of their horse and has assumed financial responsibility for costs incurred during the horse’s stay

5. Agent Name: Last First: MI:
6. Agent Address: (more)  
  City: State: ZIP:
7. Phone Numbers: Home Work Cell
  Barn Other
8. Other Contact Information Fax Email

C. Contact Information

  1. Who will be the Primary Contact Person?

    Please indicate who will act as the primary contact person for your horse, the Owner or the Agent?  This is the individual who will be contacted with routine updates and who should be in a position to make decisions about case management.
     Owner    Agent    Other (Please specify):

         Please indicate when the most convenient time during the day would be
         for us to reach you for routine updates:

    What method/number would you like us to try first for routine updates?
    Home    Work    Cell    Other phone   
    Fax    email

  2. Emergency Contact Information:
    Should a situation arise that requires rapid unscheduled contact, we will first attempt to reach the primary contact person listed above. Please list any additional individuals whom you would like for us to try to contact if the primary contact is unavailable.

    Name Contact numbers

D) ACCOMPANYING INDIVIDUAL

  1. If someone other than the owner or agent is accompanying your horse please indicate the responsible individual accompanying your horse during the visit.

    1. Who, other than the owner/agent, will be accompanying your horse to the U? 
    2. What is their relationship to the owner/horse?  Check all that apply:
      Trainer  Stable manager  Relative of owner  Friend of owner 
      Primary rider   Groom  Leasing/renting horse  Trucker 
      Other
    3. How familiar are they with the horse’s health history and presenting problem?  Check the most appropriate:
      Very familiar  Moderately familiar  Limited familiarity  Not familiar 
    4. Will an individual who is coming with the horse be able to make decisions about diagnostic and therapeutic procedures and related costs while the horse is at the U.? 
      Yes  - Name of individual
      No  - If there is not someone accompanying the horse who can make these decisions, we will need contact information for you or for someone else who can do so during the time of the horse’s scheduled visit.  Please provide the name and contact number for that individual below:
      Contact name:   
      Contact number:

VETERINARIAN INFORMATION

E) Primary Veterinarian

  1. Name of primary veterinary clinic
  2. Name of primary care veterinarians
  3. Clinic phone number
  4. Would you like for your primary care veterinarian(s) to receive communications about the status of the horse(s) currently being admitted?  Yes  No

F) Referring Veterinarian

  1. Did a veterinarian refer you to us (check one)? 
    Yes, my primary care veterinarian 
    Yes, a veterinarian other than my primary care veterinarian  If checked, please complete questions 17-19.
    No   - If checked, thank you and please submit your form.

  2. Name of referring veterinarian(s):
  3. Clinic name (s):
  4. Clinic phone number (s):
  5. Would you like for your referring veterinarian to receive communications about the status of your horse?  Yes No

(Please note that we routinely contact all referring veterinarians to gather additional information about your horse’s presenting problem and to inform them of our findings unless you specifically check “No.”)

CHECK LIST OF THINGS TO BRING TO YOUR APPOINTMENT:

  1. A copy of your pre-admission forms
  2. Insurance policies and agent contact information
  3. Records from referring or primary veterinarians
  4. Copies of previous diagnostic images (photographs, radiographs, ultrasound images, videos, scans) from other veterinarians
  5. Copies of previous laboratory (blood, biopsy, cytology) work
  6. Details on feeding, vaccination, and deworming programs

Thank you for completing the Pre-Admission Client Information. Please also complete the appropriate form for your horse (New Patient or Returning Patient) and submit both forms electronically if possible, or bring them with you to your appointment.

 

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The University of Minnesota is an equal opportunity educator and employer.

Last modified on Wednesday Feb 28, 2007

This page is located at http://www.cvm.umn.edu//eqserv/admissions/New_Client.html