Submit online, mail or bring the completed form to our hospital.
This form is needed to be able to carry a balance on your account. Without this form payment is needed at the time of service. This form is for our use only and will not be used to run credit checks. It is stored securely in a safe.
The boxes in red require some secure information such as a driver’s license number and social security number. We do not want you to put this information on the form until we come out to the farm. Please have this information available when we come out for your first farm visit. When you fill out this form, please download it onto your desktop and use the form below to send it back to us.
This form will be brought out on your first farm visit. This form allows us to NOT charge sales tax on products and medications purchased from the clinic or on products used for services. This form also requires some secure information such as a driver’s license number or social security number. Please have this information available when we come out for your first farm visit.