Equine Hospitalization and Surgical Release Form"*" indicates required fields Date* MM slash DD slash YYYY Name* First Last Owner's Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone Number*Secondary Phone NumberEmail* Best way to contactHorse InformationPatient's Name* Horse's Name Age*DOB or approximate ageBreed*Sex* Mare Gelding StallionColor*Markings*Reason for stayIs your horse insured?* Yes NoHorse Insurance Information(Company & Agent Name, if applicable)Horse Insurance Policy #Insurance Contact Phone #Morning FeedingPlease describe what/how your horse should be fed while here at Colorado Equine Clinic.Hay (AM)e.g. grass, alfalfa, mixed, etc. and quantityGrain (AM)e.g. oats, senior, etc. and quantitySupplements (AM)e.g. Myristol, Cal's Minerals, etc. and quantityMedications (AM)e.g. Equioxx, Isoxsuprine, and quantityEvening FeedingPlease describe what/how your horse should be fed while here at Colorado Equine Clinic.Hay (AM)e.g. grass, alfalfa, mixed, etc. and quantityGrain (AM)e.g. oats, senior, etc. and quantitySupplements (AM)e.g. Myristol, Cal's Minerals, etc. and quantityMedications (AM)e.g. Equioxx, Isoxsuprine, and quantityDuring the DAYTIME, my horse should be kept:* Inside OutsideOVERNIGHT, my horse should be kept:* Inside OutsideMy 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.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.*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.*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.*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.*Owner Signature*NameThis field is for validation purposes and should be left unchanged.