Springhill Equine

First Name

Last Name

Email Address

Phone

Address

City

State

Zip Code

First Patient Species First Patient Species Horse Donkey Dog Cat Goat Sheep Other

Species, if Other

Barn Address

City

State

Zip Code

Directions from nearest major road

Barn Manager/Owner, if not you

Barn Manager/Owner Phone

Horse Registered Name

Horse Nickname

Year of Birth

Color/Markings

Sex Sex Mare Gelding Stallion

Is Horse Insured? Is Horse Insured? Yes, colic only Yes, major medical No

Breed

Animal Name

Month/Year of Birth

Gender Gender Male Female Unknown

Is the Animal Spayed/Neutered? Is the Animal Spayed/Neutered? Yes No Unknown

Color/Markings

Breed

Date of Most Recent Vaccines

Would you like to add another animal? Would you like to add another animal? Yes No

Second Patient Species Second Patient Species Horse Donkey Dog Cat Goat Sheep Other

Species, if Other

Horse Registered Name

Horse Nickname

Year of Birth

Breed

Color/Markings

Is Horse Insured? Is Horse Insured? Yes, colic only Yes, major medical No

Sex Sex Mare Gelding Stallion

Animal Name

Gender Gender Male Female Unknown

Is the Animal Spayed/Neutered? Is the Animal Spayed/Neutered? Yes No Unknown

Color/Markings

Month/Year of Birth

Breed

Date of Most Recent Vaccines

Payment Acknowledgement Payment Acknowledgement I understand that payment is due at the time of service. I understand that my card number will be tokenized for my protection, and the actual number will not be stored by Springhill Equine for security purposes.

Credit Card number

Expiration Date

Security Code

Cardholder Zip Code

Treatment Authorization Treatment Authorization As the owner/agent for the above named animal(s), I authorize Springhill Equine Veterinary Clinic and their agents to treat this animal as they deem necessary. I assume responsibility for all charges incurred during the care of this animal.

Today's Date

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