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Equine Hospitalization and Surgical Release Form
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Small Animal New Client Form
Equine Hospitalization and Surgical Release Form
Download a PDF printable version here!
Date
(Required)
MM slash DD slash YYYY
Name
(Required)
First
Last
Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Phone Number
(Required)
Secondary Phone Number
Email
(Required)
Best way to contact
(Required)
Text
Email
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
No
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)
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)
I 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)
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)
I have read and acknowledge the above
(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)
Email
This field is for validation purposes and should be left unchanged.
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