Equine Wellness and Performance of Central Florida

New Patient Form

Welcome

Equine Wellness and Performance is a full service equine-focused veterinary practice servicing Brevard County and the surrounding Central Florida area. We offer a wide range of services including in-clinic care, ambulatory services, reproductive services, field surgical services, sports medicine, rehabilitation, and 24/7 emergency care.

What is a patient: To be considered a patient, a horse must have had a wellness visit within 12 months.

New patient information

Name:

Email:

Mobile phone:

Secondary phone

Address

City

State

Zip Code

Horse 1 (Show name, barn name, breed, sex, color, age, microchip #)

Horse 2 (Show name, barn name, breed, sex, color, age, microchip #)

Barn contact name

Barn address

Barn contact phone number

I want to authorize emergency treatment and consent

Yes

Name for authorized person

Phone number for authorized person

Free Text

Equine Wellness and Performance offers an Annual Wellness Plan. If you would like to to sign up for the plan, please check the box below and provide billing information at the end of this form or call the office to arrange payment.

Healthcare Sign-Up

I want to sign up for the plan ($395)

Do not sign me up

Free Text

In order for treatment to be provided by an authorized person, a current Visa or Mastercard must be on file. Please provide that information below. Please also indicate the maximum authorization for emergency care.

Credit Card Number

Credit Card expiration

Authorization amount