New Client Registration

New Client Registration
Thank you for choosing Tacoma Equine Hospital to care for your horse, donkey, or mule! Please fill out the following form so we can ensure that we have all of your correct information. You will need the address of where your horse is located as well as your driver license to complete this form.
Owner Information
Name*

First NameLast Name
Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone*

Mobile (Cell)Home
Mobile Number

Area CodePhone Number
Home Phone

Area CodePhone Number
Driver License*
DL State of Issue*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*

MonthDayYear
Spouse or Co-Owner?*

YesNo
Spouse/Co-owner Information
Spouse/Co-owner Name

First NameLast Name
Spouse/Co-owner Email Address
example@example.com
Spouse/Co-owner Phone Number

Area CodePhone Number
Spouse/Co-owner Driver License
DL State of Issue

Street Address

Street Address Line 2

CityState

Zip Code
Spouse/Co-owner Date of Birth

MonthDayYear
Date
Horse Information
Name*
Breed*
Color*
Date of Birth *

MonthDayYear
Estimate if you are not sure.
Sex*

FemaleGeldingStallion
Microchipped*

YesNoUnknown
Date of Last Vaccinations

MonthDayYear
Date
What vaccines did they receive?
Date of Last Dental

MonthDayYear
Date
Date of Last Deworming

MonthDayYear
Date
Current Medication(s) or Health Conditions*
Other Medical History
Do you have another horse?*

YesNo
Second Horse Information
Name
Breed
Color
Date of Birth

MonthDayYear
Estimate if you are not sure.
Sex

FemaleGeldingStallion
Microchipped

YesNoUnknown
Date of Last Vaccinations

MonthDayYear
Date
What vaccines did they receive?
Date of Last Dental

MonthDayYear
Date
Date of Last Deworming

MonthDayYear
Date
Current Medication(s) or Health Conditions
Other Medical History
Do you have another horse?

YesNo
Third Horse Information
Name
Breed
Color
Date of Birth

MonthDayYear
Estimate if you are not sure.
Sex

FemaleGeldingStallion
Microchipped

YesNoUnknown
Date of Last Vaccinations

MonthDayYear
Date
What vaccines did they receive?
Date of Last Dental

MonthDayYear
Date
Date of Last Deworming

MonthDayYear
Date
Current Medication(s) or Health Conditions
Other Medical History
Do you have another horse?

YesNo
Fourth Horse Information
Name
Breed
Color
Date of Birth

MonthDayYear
Estimate if you are not sure.
Sex

FemaleGeldingStallion
Microchipped

YesNoUnknown
Date of Last Vaccinations

MonthDayYear
Date
What vaccines did they receive?
Date of Last Dental

MonthDayYear
Date
Date of Last Deworming

MonthDayYear
Date
Current Medication(s) or Health Conditions
Other Medical History
Do you have another horse?

YesNo
Fifth Horse Information
Name
Breed
Color
Date of Birth

MonthDayYear
Estimate if you are not sure.
Sex

FemaleGeldingStallion
Microchipped

YesNoUnknown
Date of Last Vaccinations

MonthDayYear
Date
What vaccines did they receive?
Date of Last Dental

MonthDayYear
Date
Date of Last Deworming

MonthDayYear
Date
Current Medication(s) or Health Conditions
Other Medical History
Do you have another horse?

YesNo
Sixth Horse Information
Name
Breed
Color
Date of Birth

MonthDayYear
Estimate if you are not sure.
Sex

FemaleGeldingStallion
Microchipped

YesNoUnknown
Date of Last Vaccinations

MonthDayYear
Date
What vaccines did they receive?
Date of Last Dental

MonthDayYear
Date
Date of Last Deworming

MonthDayYear
Date
Current Medication(s) or Health Conditions
Other Medical History
If you have additional horses please email us their information at info@tacomaequine.com
Horse Location
Facility Name
if applicable
Address*

Street Address

Street Address #2

CityState / Province

Postal / Zip Code
Previous Veterinarian
Do you have a previous veterinarian?*

YesNo
Name of Previous Veterinarian
Name of Previous Clinic
May we request records for all your horses from your previous veterinarian?*

YesNo
Referral
How did you hear about us?*

Barn/TrainerFeed StoreFriend/FamilyHorse Health ExpoI was a previous clientWeb SearchVeterinarianOther
Who can we thank?
Financial Policy
Tacoma Equine Hospital requires payment in full at the time of service. I assume financial responsibility for all charges incurred to the patient for services rendered. In the event of default of payment and/or failure to pay, I agree to pay the costs of collection, including court costs and reasonable attorney fees to be determined by a court of law.
Signature*

Clear
Comments/Questions & Submit
If you have any comments or questions, please add them here.
Should be Empty:

New Client Registration

Owner Information

Spouse/Co-owner Information

Horse Information

Second Horse Information

Third Horse Information

Fourth Horse Information

Fifth Horse Information

Sixth Horse Information

Horse Location

Previous Veterinarian

Referral

Financial Policy

Comments/Questions & Submit