Equine Hospitalization and Surgical Release Form

Date(Required)

Name(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Primary Phone Number(Required)

Secondary Phone Number

Email(Required)

Best way to contact(Required)

Text

Phone call

Horse Information

Patient's Name(Required)

Age(Required)

DOB or approximate ag

Breed(Required)

Sex(Required)

Mare

Gelding

Stallion

Color(Required)

Markings(Required)

Reason for stay

Is your house insured?(Required)

Yes

Morning Feeding

Please describe what/how your horse should be fed while here at Colorado Equine Clinic.

Hay (AM)

e.g. grass, alfalfa, mixed, etc. and quantity

Grain (AM)

e.g. oats, senior, etc. and quantity

Supplements (AM)

e.g. Myristol, Cal's Minerals, etc. and quantity

Medications (AM)

e.g. Equioxx, Isoxsuprine, and quantity

Evening Feeding

Please describe what/how your horse should be fed while here at Colorado Equine Clinic.

Hay (PM)

e.g. grass, alfalfa, mixed, etc. and quantity

Grain (PM)

e.g. oats, senior, etc. and quantity

Supplements (PM)

e.g. Myristol, Cal's Minerals, etc. and quantity

Medications (PM)

e.g. Equioxx, Isoxsuprine, and quantity

During the DAYTIME, my horse should be kept:

Inside

Outside

OVERNIGHT, my horse should be kept:

Inside

Outside

My horse should be blanketed if the temperature is under:

Additional notes about my horse's stay:

You are welcome to visit your horse any time while at CEC. We ask that you please:

Ask permission before taking your horse from his stall.
Do not clean your horse’s stall. Observing manure is an important part of our exams.

Consent

By checking this box, I authorize my horse to be photographed/videoed by CEC staff for educational and promotional purposes. Names will be kept anonymous, but images may be seen in a public environment.

I hereby certify that I own the above described animal and I do hereby consent and authorize Colorado Equine Clinic and its staff to hospitalize my horse, administer vaccinations, medications, tests, surgical procedures, anesthetics, or treatments that are deemed necessary for the health, safety, and well-being of the above animal while under their care and supervision.(Required)

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If my horse should injure itself in an escape attempt, refuse food, become ill, or die while in the hospital, I will hold Colorado Equine Clinic and the staff free of any responsibility and/or liability in the absence of gross negligence.(Required)

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I further realize that I am responsible for payment for the indicated procedures and treatments in full at the time the animal is discharged unless other arrangements have been made. If I neglect to pick up the animal within five days of verbal notice that he or she is ready for release, the animal is considered abandoned. Abandonment does not release my obligations to the bill.(Required)

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I agree that in the case of non-payment a finance charge of 1.5% per month (18% annum) will be charged and that any collection fees or attorney fees will be paid by me.(Required)

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Please read before signing:(Required)

I acknowledge

Please leave your halter with the office staff! We will store it for you until pick up. You are welcome to visit your horse any time while at CEC. We ask that you please: •Ask permission before taking your horse from the stall. •Do not clean your horse's stall. Observing the stall is an important part of our exams. Thank you!

Signature(Required)

Phone

This field is for validation purposes and should be left unchanged.

Equine Hospitalization and Surgical Release Form

Horse Information

Morning Feeding

Evening Feeding

Contact Us

Clinic Hours of Operation