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What is a Certified Vet Tech?
Our Team
New Clients
Equine
Equine Hospitalization and Surgical Release Form
Equine New Patient Registration
Small Animal
Small Animal New Client Form
Equine New Patient Registration
Download a PDF printable version here!
Name
(Required)
First
Last
Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
(Required)
Primary Phone Number
(Required)
Can you receive texts on this phone?
(Required)
Yes
No
Preferred Method of Contact
(Required)
Do you have an additional contact to add?
(Required)
Yes
No
Name
First
Last
Phone
Email
Preferred contact method
Phone call
Email
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Is horse insured?
(Required)
Yes
No
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.
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