Clinic Registration Form

* Approximate Arrival Date / Time: * Veterinarian:
* Owners Name    
* Owner Address: * City:
 
* State: * Zip:
* Phone Number:    
 
Emergency Contact Information
At least one required
* Contact Name: * Phone Number:
Contact Name: Phone Number:
 
Patient Information
Horse Name: Breed:
Color:
Age:    
Reason for Admittance:
Culture/Cytology Results:    
Date:    
       
Breeding History:    
Medical Notes/Alerts/Vices:
If Breeding, semen to arrive on via Federal Ex.
Semen Located at SBS:
Shipped Semen From:
Stallion Name:
Stallion Owner Name:    
Stallion Owner Phone:    
Rental Tank Needed:    
 
Vaccine History:
Please provide most recent date of vaccinations
Rabies:
Botulism:
EWT:
WN:
Strangles:
INF/RHINO: (must be with given within 60 days but not with in 7 days of arrival)
Coggins: Negative fecal or lastde-worming date: (must be no more than 30 days from arrival)
Please provide a copy of vaccine history and negative coggins with in one year prior to arrival.
 
Feeding Instructions: Grain will not be supplied unless requested
AM: Grain Amount AM: Hay
PM: Grain Amount PM: Hay
Special Requests:
Special Handling/Behavioral Traits:
 

The animal listed above has been admitted to Unionville Equine Associates, P.C. for medical treatment. Questions regarding treatment should be directed to the clinician in charge. A $500.00 deposit will be charged to the credit card supplied on the date of arrival and payment for all services is due upon discharge of the animal. The animal will be expected to be picked up within twenty four hours after the owner/agent is notified that the animal is ready to be discharged, unless prior arrangements are made. Failure to pick up the animal within three days could result in the animal being considered to be abandoned.

I hereby release and hold Unionville Equine Associates, P.C., its officers, employees and agents harmless from any claims for loss or injury to my animal by reason of medical treatment and/or handling which it renders pursuant to this admission. I hereby state that I am the owner of the above animal, or I am a duly authorized agent of the owner. I have read all of the above conditions and hereby agree to the same.

A copy of this form will be provided at the time the horse is admitted:
A credit card must be supplied to our office within 24 hours of the submission of this form. The exam will not be scheduled until a credit card is supplied to our office.