3H Equine Hospital New Client Form

3H Equine Hospital
3H Equine Hospital and Mobile Veterinary Services 464 Southern Pecan Ln New Hill, NC 27562
P: (919) 363-1686 / F: (919) 363-1682
3H Equine Veterinary Hospital

464 Southern Pecan Lane

New Hill, NC 27526
Name

First NameLast Name
Driver License #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile
Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact (Name & Phone Number):
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Location of Horse :

Boarding facility or Private property
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Horses Name
Breed
Color
Age
Gender
Horse #2:
Breed
Color
Age
Gender
Microchip Number (if applicable):
Previous Medical History include any chronic conditions or past surgeries
Current Medications and Supplements
Vaccination History please provide records or dates

MonthDayYear
Date
Deworming History include dates and products used

MonthDayYear
Date
Recent Health Issues or Complaints
Primary Use of Horse (eg competition, pleasure riding, breeding)
Veterinary Care
Do you have any specific concerns or preferences regarding your horses care:
Emergency Information (if different from our hospital):
Name
Phone Number
Format: (000) 000-0000.
Do you authorize our hospital to proceed with emergency treatment if you cannot be reached?:
Do you want to set a limit on finances if you are unable to be reached?:
Payment Policy: Payment is due at the time of service. A credit card is required to book an appointment.
How do you plan to handle payment?
Name
Address
Phone Number
Format: (000) 000-0000.
Insurance Provider (if applicable):
Provider Name
Policy Number
Note
Is there any other information you think we should know about your horse or your preferences
I, [Owner's Full Name], consent to the examination and treatment of my horse by the veterinary staff at 3H Equine Hospital. | understand that payment is due at the time of service, a credit card is required to book an appointment, and that we do not accept payments directly from insurance companies. I am responsible for paying the invoice upfront and will seek reimbursement from my insurance provider.
I Owners Full Name
Signature
Should be Empty:

3H Equine Hospital

P: (919) 363-1686 / F: (919) 363-1682