Client InformationOwner First Last Home PhoneWork PhoneCell PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email Referring VeterinarianPhoneTrainer / AgentPhonePatient InformationHorse's Registered NameHorses Barn NameAgeBreedSexColor / MarkingsReason for admissionVaccine History (Dates) - 1Sleeping SicknessRhinovirusStranglesTetanusWest Nile Vaccine History (Dates) - 2PotomacInfluenzaRabiesRotavirusOther Last Deworming DateType of DewormerDoes your horse have current negative coggins? Yes No If yes please bring copy with youEVA Tested Yes No EVA Results Positive Negative N/A EVA Vaccinated Yes No Is there anything about your horse we should be aware of? (for example; difficult to catch, doesn’t tie, allergies, past medical treatments/conditions, etc.)Breeding InformationName and breed of the mare your stallion is being bred toIf shipping semen, please list mare owner’s name, phone number & shipping address:Special breeding / handling instructions:Will the semen be used for: A.I. Shipped Cooled Frozen Feeding InstructionsWe recommend you to bring your horses regular grain otherwise a ration balancer will be provided.How much hay does your horse eat (in flakes)How many times daily?How much grain does your horse eat?How many times daily?Is your horse currently on any medications?Turn out instructions:Will you be leaving your trailer? Yes No If yes, license plate #:Note: Halters should be left with your horse. However, all other accessories such as lead ropes, blankets, leg wraps, etc., should be taken home with you unless needed for turn out. Cleary Lake Veterinary Hospital will not be responsible for loss or theft of any items left with your horse. TREATMENT CONSENT I hereby authorize the performance of those diagnostic, anesthetic, surgical and therapeutic procedures as recommended, in the best interest of my horse by the clinical staff of Cleary Lake Veterinary Hospital. I understand that all reasonable precautions will be taken to assure the safety and well being of my horse while in the breeding centre. I have been advised as to the nature of the procedure(s) or operation(s) and the risks involved. I realize that results cannot be guaranteed. I understand that during the performance of the foregoing procedure(s) or operation(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or operation(s) or different procedure(s) than those set fourth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are necessary and desirable in the exercise of the veterinarian’s professional judgment. I have read and signed this authorization and consent. Payment PolicyDEPOSIT IS REQUIRED UPON ADMITTANCE; FULL PAYMENT IS DUE UPON DISCHARGE. Please indicate your choice of payment below Cash Check Credit Card / CareCredit A $30 service charge will be assessed for a returned check. I have discussed the estimate costs for the procedure(s) with a staff member of Cleary Lake Veterinary Hospital and I fully understand I am financially responsible for all costs incurred including 1 ½ % interest or $1.00 billing charge, whichever is greater, assessed monthly on unpaid balance. Signature of Owner / Agent*Date* MM slash DD slash YYYY Emergency PhoneCAPTCHA