New Client Registration FormNew Client Registration Form Client NameClient Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern 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CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Stable NameStable Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneWork PhoneCell Phone #1Cell Phone #2Email AddressBarn Manager Name & Phone NumberTrainer Name & Phone NumberHorse InformationPlease note: Your privacy is important to us. All information received in all forms and through other communications is subject to our Patient Privacy Policy.Please list your horse(s) and their details.NameAge/DOBBreedSexColor You may fill for up to 10 horses.If you are unreachable, who should we contact in case of an emergency? Please list Name & Phone Number'sPrevious or Current Veterinarian: We would appreciate having any previous medical records for your horse. Please share these records to office@crossrivervetservice.com. Please include any relevant medical history we should be immediately aware of.If Referred, Whom may we thank for referring you?Consent*All Payments are due at the time of services rendered. I agree that I have read the above statement and agree to all terms therein.Consent*Client Expectations Welcome to Cross River Veterinary Service! We are grateful that you have chosen our practice to be part of your horse’s veterinary care team. We look forward to many healthy and happy years working together! Cross River Veterinary Service is a compassionate, responsible veterinary team dedicated to providing progressive, high quality, ambulatory veterinary care for equine athletes and equine companions. We are focused on continual advancement of our medical knowledge and service to our patients and aim to exceed our client’s expectations. 1. Office hours: Monday-Friday: 9 AM-4 PM • Phone calls to our main number 610-588-9467 will be answered as soon as possible during office hours. • Texting is reserved for office hours only. Text messages and voicemails left after hours or on weekends will not be accessed until the following business day. You may have had the privilege of texting or calling one of the veterinarian’s cell phone numbers when your horse was sick. Please refrain from using that number for routine questions, especially outside of normal business hours. • If you have an after-hours emergency or need to speak to a veterinarian on call, please call the emergency line at 570-476-8467. 2. Emergencies: While we hope you don’t need us for emergency care, rest assured we are available 24/7 for any emergency veterinary needs that may arise. • Emergency veterinary care is provided to current active clients of Cross River Veterinary Service. • Cross River Veterinary Service has partnered with All Points Equine to share weekend and after-hours emergency coverage for our practices while maintaining work-life balance. • If you have an equine medical emergency or need to speak to the veterinarian on call, please call the emergency number at 570-476-8467 and they will direct you to the on-call veterinarian from one of the practices. If you do not receive a call back in 15-30 minutes, please call again. • Clients must be considered “in good standing,” and we reserve the right to deny coverage to active clients with overdue unpaid balances. Notice will be provided in advance of cessation of emergency coverage. 3. How do I become a current and active client? • Cross River Veterinary Service requires an active Veterinary-Client-Patient relationship in order to be considered a current client and to be eligible for emergency veterinary care. In order to maintain an active Veterinary-Client-Patient relationship, Cross River Veterinary Service must have seen your horse(s) within the last 12 months for routine/wellness care and they must reside within the geographical practice area. If Cross River Veterinary Service has not provided care to your horse(s) within the last 12 months, or your horse is moved outside the geographic practice area, the Veterinary-Client-Patient relationship will be lapsed and emergency care may not be provided. • If your horse(s) are under our care and you move your horse(s), please notify our office as soon as possible to ensure that our Veterinary-Client-Patient relationship remains active. 4. Payment is due at the time of service. Payment is expected at the time services are rendered. If you are unable to attend your appointment in person, please make appropriate arrangements with our office. Veterinary Care Team Communications: • We understand that some clients may utilize multiple veterinarians as part of their horse’s veterinary care team and open lines of communication are essential within such a team. • So that we may prevent any possible medical errors or injuries from occurring to your horse, we ask that you share with us any relevant treatment or diagnosis made by another veterinarian on your horse’s care team. Relevant medical records from another practice can be emailed to our office and added to your horse’s file to ensure all veterinarians are up to date on your horse’s veterinary care. We are also happy to share our files with the other members of your horse’s care team. Cross River Veterinary Service- Kelly Corcoran, VMD & Megan Eick, DVM I agree to the above Client Expectations and Veterinarian-Client-Patient-Relationship Terms.Signature*Date* MM slash DD slash YYYY CAPTCHA