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Equine New Patient Registration

Download a PDF printable version here!

Name(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Email(Required)

Primary Phone Number(Required)

Can you receive texts on this phone?(Required)

Yes

Preferred Method of Contact(Required)

Do you have an additional contact to add?(Required)

Yes

Name

First Last

Phone

Preferred contact method

Phone call

Text

Preferred Payment Method(Required)

Cash

Check

Credit Card - Visa, Discover, Mastercard, American Express

Care Credit - Only certain Payment Plans accepted

Who may we thank for referring you or how did you hear about us?(Required)

Why did you choose CEC?(Required)

Horse Information

Horse's Show Name

i.e. Registered Name

Horse's Barn Name(Required)

Breed(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Sex(Required)

Mare

Gelding

Stallio

Color(Required)

Tattoo (if applicable)

Markings(Required)

Name of Stable (If Boarded)

Stable Address

Street Address City State ZIP Code

Is horse insured?(Required)

Yes

Known Allergies(Required)

Significant History

(serious illness, lameness, colic, etc.)

Trainer Name (If Applicable)

First Last

Submit Form

Please upload any medical records, medical imaging, pictures, videos or other relevant information here

Accepted file types: jpg, gif, png, pdf, mp4, mov, Max. file size: 32 MB.

Payment Policy: In order to keep costs low for all clients, please note that payment is due at the time of service. We accept cash, check, Care Credit (limited promotions), and Visa, Discover, MasterCard, and American Express credit and debit cards. Please be prepared to pay your balance in full before departure. Thanks! ~The CEC Team

Signature(Required)

Comments

This field is for validation purposes and should be left unchanged.

Contact Us

Address: 9616 W Titan Rd | Littleton, CO 80125

(303) 791-4747
wellness@coequine.com

Clinic Hours of Operation

Monday – Friday: 8:00am – 5:00pm

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