Equine Partners Inc. Dr. Carl Gray
740-817-0446
CLIENT INFORMATION FORM
EQUINE PARTNERS, INC.
DR. CARL GRAY
3538 NORTHRIDGE RD
ALEXANDRIA, OH 43001
740-924-9111
740-817-0446 CELL
Client/Owner Name: ____________________________________________________________
Person Responsible for payment (if other than client/owner) ____________________________
Telephone: Cell: ____________________ Home: __________________ Work: _____________
E-mail address_________________________________________________________________
I would like to receive e-mail: reminders invoices/statements other information
Horse Stabled at: _______________________________________________________________
Horse Description
Registered Name Nickname DOB Breed Sex Color
______________ ____________ ______ ________ ____ ____________
______________ ____________ ______ ________ ____ ____________
______________ ____________ ______ ________ ____ ____________
I hereby authorize Dr. Carl Gray at Equine Partners Inc. to perform veterinary services on my horses to a limit of $___________. Payments are due when services are rendered. Credit will be extended and services billed with prior approval. In these cases the account is payable in full within 30 days. Accounts not paid in full within 30 days will be charged interest of 1.5 % per month on the balance due. Any non payments of accounts may result in denial of future veterinary services. If legal action is necessary to collect unpaid invoices all costs of collection will be charged to debtor.
Signature: ________________________________________ Date________________________
If you have not done so already, or if your information has changed, please print this form, fill in the blanks, and return it by mail. Please call with any questions.
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