Step 1: Client Information Form

Lisa Wagner, D.V.M.
Diplomate, ACVIM

We are accepting new clients at this time.
Please fill out our Client Information form below and
we will contact you shortly!
If you have any questions, please call the office at 540-822-5927.

Client information

* Indicates required field

Client/Owner Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Employment: *

Cell Phone Number *

Home Phone Number *

Work Phone Number *

Email *

In an effort to reduce paper waste, Wagner Equine sends the majority of invoices, receipts, and other non-sensitive communication electronically via email. If you would prefer to receive all correspondence in the mail, please check below:

Select One *

Horse information

Horse #1: Name *

Breed *

Age *

Color *

Sex *

Insured *

Horse #2: Name *

Breed *

Age *

Color *

Sex *

Insured *

Horse #3: Name *

Breed *

Age *

Color *

Sex *

Insured *

Horse #4: Name *

Breed *

Age *

Color *

Sex *

Insured *

Horse(s) Stabled At *

Farm Address *

Comments *

Thank you for completing our Client Information form. Prior to your first appointment, please complete the registration process by signing the Consent to Veterinary Services form.

Submit

We are accepting new clients at this time. Please fill out our Client Information form below and we will contact you shortly! If you have any questions, please call the office at 540-822-5927.

Client information

Horse information

We are accepting new clients at this time.
Please fill out our Client Information form below and
we will contact you shortly!
If you have any questions, please call the office at 540-822-5927.