Returning Client Form, University of Minnesota Equine Clinical Services

A.  Owner Information

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

C) Who will be the Primary Contact Person?

9.  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):

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

10. 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.

D) ACCOMPANYING INDIVIDUAL
11. 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

12. Name of primary veterinary clinic
13. Name of primary care veterinarians
14. Clinic phone number
15. 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

16. 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 15-18.
    No   - If checked, thank you and please submit your form.

17. Name of referring veterinarian(s):
18. Clinic name (s):
19. Clinic phone number (s):
20. 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.