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Equine Hospitalization and Surgical Release Form

Download a PDF printable version here!
This field is for validation purposes and should be left unchanged.
MM slash DD slash YYYY
Name(Required)
Address(Required)
Best way to contact(Required)

Horse Information

DOB or approximate ag
Sex(Required)
Is your house insured?(Required)

Morning Feeding

Please describe what/how your horse should be fed while here at Colorado Equine Clinic.
e.g. grass, alfalfa, mixed, etc. and quantity
e.g. oats, senior, etc. and quantity
e.g. Myristol, Cal's Minerals, etc. and quantity
e.g. Equioxx, Isoxsuprine, and quantity

Evening Feeding

Please describe what/how your horse should be fed while here at Colorado Equine Clinic.
e.g. grass, alfalfa, mixed, etc. and quantity
e.g. oats, senior, etc. and quantity
e.g. Myristol, Cal's Minerals, etc. and quantity
e.g. Equioxx, Isoxsuprine, and quantity
During the DAYTIME, my horse should be kept:
OVERNIGHT, my horse should be kept:
You are welcome to visit your horse any time while at CEC. We ask that you please:
  • Ask permission before taking your horse from his stall.
  • Do not clean your horse’s stall. Observing manure is an important part of our exams.
Consent
I hereby certify that I own the above described animal and I do hereby consent and authorize Colorado Equine Clinic and its staff to hospitalize my horse, administer vaccinations, medications, tests, surgical procedures, anesthetics, or treatments that are deemed necessary for the health, safety, and well-being of the above animal while under their care and supervision.(Required)
If my horse should injure itself in an escape attempt, refuse food, become ill, or die while in the hospital, I will hold Colorado Equine Clinic and the staff free of any responsibility and/or liability in the absence of gross negligence.(Required)
I realize that I am responsible for payment for the indicated procedures and treatments in full at the time the animal is discharged unless other arrangements have been made. If I neglect to pick up the animal within five days of verbal notice that he or she is ready for release, the animal is considered abandoned. Abandonment does not release my obligations to the bill.(Required)
I agree that in the case of non-payment a finance charge of 1.5% per month (18% annum) will be charged and that any collection fees or attorney fees will be paid by me.(Required)
I have read and acknowledge the above(Required)
Please leave your halter with the office staff! We will store it for you until pick up. You are welcome to visit your horse any time while at CEC. We ask that you please: •Ask permission before taking your horse from the stall. •Do not clean your horse's stall. Observing the stall is an important part of our exams. Thank you!
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