Elite Equine
Veterinary Dentistry
www.eevetdentistry.com
701-540-8914
Tanya Borud, DVM
Client Name: ________________________ ______________________________
Last
First
Spouse/Other: ________________________ ______________________________
Last
First
Mailing Address: _________________________ City _____________ State ______ Zip _______
Home Phone: ________________ Cell Phone: _______________E-MAIL ADDRESS: _______________________________
Cell phone provider if you wish to receive text messages for reminders: ________________________________________
Preferred Method of Payment: CASH ( ) CHECK ( ) MAJOR CREDIT CARD ( )
Payment is DUE AT TIME OF SERVICE and there will be a service charge of $30 added to any NSF check at collection time
How did you hear about us? Flyer ( ) Facebook ( ) Friend ( ) Website ( ) Other ( )
Name of person(s), store or paper which referred you: _______________________________________
Horse #1
Call Name
Registered Name
Breed
DOB/Age
Sex
Color
Markings/Brands
Primary Use
Requested Services
(Float, coggins,
vaccines, etc)
Horse #2
Horse #3
Horse #4
Horse #5
Horse #6