Cleary Lake Veterinary Hospital, Prior Lake, Minnesota

Name*

First Last

Spouse

First Last

Parent / Guardian (if under 18 years)

First Last

Address

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Cell Phone

Email*

Spouse Cell Phone

Work Phone / EXT

Spouse Work Phone / EXT

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Equine Information

Name*

Breed*

Sex*

Color*

Age*

Stabled At*

Phone*

Stable Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Name*

Breed*

Sex*

Color*

Age*

Stabled At*

Phone*

Stable Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

By checking here I authorize the owner and his/her agents at the boarding stable to make routine and emergency vet appointments, order medication and treatments for my horse(s) on my behalf and I agree to pay for all veterinary expenses requested by the stable owner and agents.

Emergency Contact

In the event of an emergency and I (and my spouse) cannot be reached (list names below) to make emergency appointments, I authorize order medication and treatments for my horse(s) on my behalf and I agree to pay for all veterinary expenses.

Name

First Last

Phone

Date*

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