Veterinary Service Agreement
Harmony Hills Veterinary Services, PLLC
By filling out this form and requesting service:
You affirm that you are over 18 years of age AND
You are the legal owner and/or authorized agent of the animal(s) for which you are requesting service.
Horse Owner Information
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Name and phone number of additional owners/authorized individuals
Enter Horse Information
Rows
Horse Name
Age/DOB
Gender
Color
Breed
Tattoos/Microchip/Markings
Use
1
2
3
4
5
Additional Horse Information
Insurance Information (if any)
Known Veterinary/Health Issues (please explain): Please include vaccination history, Coggins, deworming program and current medications if known.
Authorized Agents (trainer, barn owner, etc.)
Disclosure to Authorized Agents
Permission to contact via text (SMS) message.
*
Payment Policy
*
Emergency Services
*
Today's Date:
Signature
*
Submit
Submit
Should be Empty: