LA PALOMA EQUINE CLINIC

                                                 P. O. BOX 30

                                       WALLER, TEXAS  77484

         936-931-9100  FAX: 281-966-6996   E-MAIL –lapalomaequine@yahoo.com

 

                                        CLIENT /HORSE INFO SHEET

 

OWNER: _________________________________________________________ 

ADDRESS: _______________________________________________________

                    _______________________________________________________

BILLING ADDRESS:  ______________________________________________

                                      ______________________________________________

E-MAIL ADDRESS: ________________________________________________

HOME PHONE: ___________________ CELL PHONE: ___________________

WORK PHONE: ___________________ PAGER #: _______________________

FAX NUMBER: ____________________________________________________

 

HORSE’S REGISTERED NAME:______________________________________

HORSE’S BARN NAME: ____________________________________________

HORSE’S AGE/SEX/COLOR/BREED __________________________________

INSURANCE PROVIDER:____________________________________________

POLICY # ____________________  PHONE # ___________________________

 

HORSE’S REGISTERD NAME: ______________________________________

HORSE’S BARN NAME: ____________________________________________

HORSE’S AGE/SEX/COLOR/BREED __________________________________

INSURANCE PROVIDER: ___________________________________________

POLICY # ___________________ PHONE # _____________________________

 

HORSE’S REGISTERD NAME: ________________________________________

BARN NAME: ______________________________________________________

HORSE’S AGE/SEX/COLOR/BREED ___________________________________

INSURANCE PROVIDER: ____________________________________________

POLICY # ______________  PHONE # ___________________________________

 

HAS ANY MARES LISTED ABOVE BEEN IN FOAL  Y______  N____________

DO ANY OF YOUR HORSES HAVE ALLERGIES TO DRUGS?  _____________

STABLE NAME (IF APPLICABLE) ______________________________________

IS THIS HORSE/HORSES A CANIDATE FOR  COLIC SURGERY  Y____ N____

WHO IS YOUR PREFERRED SURGICAL FACILITY? ______________________

 

IN AN EFFORT TO KEEP COST DOWN, PAYMENT IS DUE AT TIME OF SERVICE.  IT IS OUR POLICY TO KEEP A CREDIT CARD ON FILE IF YOU CANNOT BE PRESENT WITH A CHECK.  NO BILLING WILL BE DONE WITHOUT ADVANCE NOTICE.

TYPE:______  CC # ______________________________ EXP._____   CCV _______