Veterinary Service Agreement
Harmony Hills Veterinary Services, PLLC
Horse Owner Information
*Account must be set up by an authorized individual over 18 years of age*
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Name and phone number of additional owners/authorized individuals
Enter Horse Information
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):
Authorized Agents (trainer, barn owner, etc.)
Disclosure to Authorized Agents
Permission to contact via text (SMS) message.
Urgent Care and Emergencies
Emergency Services
*
Signature
*
Submit
Submit
Should be Empty: