Owner Name

First Name

Last Name

Owner Phone Number

(###)

###

####

Owner Email Address

Owner Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Trainer/Agent Name

First Name

Last Name

Trainer Phone Number

(###)

###

####

Trainer Email Address

Primary Veterinarian Name

Clients are required to have a valid Veterinarian-Client-Patient Relationshipi (VCPR) with their primary care veterinarian; this means that an exam must have been performed by your primary care veterinarian within the last year.

First Name

Last Name

Primary Veterinarian Phone Number

(###)

###

####

Primary Veterinarian Email Address

Patient Name

Patient Age

Patient Gender

Patient Breed

Patient Color

Patient Profession

Please also include level of competition if applicable (ie 3' Hunter or Prix St George Dressage)

Patient Area of Interest

What is your main concern for today's appointment?

Patient Boarding Location

The Patient Boarding Location is where the pet resides (if separate from owner mailing address). Please include farm name and gate code if applicable as well as specific barn if it is a multi-farm property.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How did you hear about us? If you were referred, please include the name of the person who recommended Del Dios Veterinary Acupuncture so that we can properly thank them!

Select Payment Option

Please note that payment is due at time of service. Cash, personal check, or ACH payment (Zelle) are preferred. If paying with credit card, please see description below for authorization of credit card payment.

Credit Card Payment Authorization

**PLEASE NOTE**Credit Card Number will be taken ONLY in person or over the phone and will be stored securely on the QuickBooksOnline encrypted server.

By checking this box you authorize Del Dios Veterinary Acupuncture to charge the credit card provided for services rendered at the time of service.

I understand that credit card merchant fees may be charged for the convenience of having a card on file.

Cancellation Policy

Cancellations made within 24 hours of the appointment time will be charged 50% of an appointment fee. Cancellations at time of appointment/"No Shows" will be charged 100% of appointment and call fees.

I have read and understand the cancellation policy.

New Client Information

Please complete the New Client form below—

The New Client form is required prior to your appointment so that Dr. Aumann Can provide the best possible treatment for your horse or Dog

Once you have clicked Submit, Dr. Aumann will have received your form and will contact you within 1-2 business days. For Questions please call 781-820-1851 or email office@deldiosdvm.com

Hyperlink to Human 5-element personality questionnaire.

New Client Information

Please complete the New Client form below—

** The New Client form is required prior to your appointment so that Dr. Aumann Can provide the best possible treatment for your horse or Dog**

Once you have clicked Submit, Dr. Aumann will have received your form and will contact you within 1-2 business days. For Questions please call 781-820-1851 or email office@deldiosdvm.com

Hyperlink to Human 5-element personality questionnaire.

The New Client form is required prior to your appointment so that Dr. Aumann Can provide the best possible treatment for your horse or Dog