Springhill Equine New Client Form 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 Please type your full name as your valid electronic signature 5 + 3 = Submit
