Hospitalization And Surgical Release Form

Horse Information
Patient Name *
Age *
DOB or approximate age
Breed *
Sex *

Mare Gelding Stallion
Color *
Markings
Reason for Stay
Is your horse insured?

Yes No
Horse Insurance Information
(Company & Agent Name, if applicable)
Horse Insurance Policy #
Insurance Contact Phone #

Area Code Phone Number
Morning Feeding

Please describe what/how your horse should be fed while here at Colorado Equine Clinic.
Hay (AM)
e.g. grass, alfalfa, mixed, etc. and quantity
Grain (AM)
e.g. oats, senior, etc. and quantity
Supplements (AM)
e.g. Myristol, Cal's Minerals, etc. and quantity
Medications (AM)
e.g. Equioxx, Isoxsuprine, and quantity
Evening Feeding

Please describe what/how your horse should be fed while here at Colorado Equine Clinic.
Hay (PM)
e.g. grass, alfalfa, mixed, etc. and quantity
Grain (PM)
e.g. oats, senior, etc. and quantity
Supplements (PM)
e.g. Myristol, Cal's Minerals, etc. and quantity
Medications (PM)
e.g. Equioxx, Isoxsuprine, and quantity
During the DAYTIME, my horse should be kept: *

Inside Outside
OVERNIGHT, my horse should be kept: *

Inside Outside
My horse should be blanketed if the temperature is under:
Additional notes about my horse's stay:
You are welcome to visit your horse any time while at CEC. We ask that you please:
- Ask permission before taking your horse from his stall.
- Do not clean your horse’s stall. Observing manure is an important part of our exams.

Submit
By checking this box, I authorize my horse to be photographed/videoed by CEC staff for educational and promotional purposes. Names will be kept anonymous, but images may be seen in a public environment.
I hereby certify that I own the above described animal and I do hereby consent and authorize Colorado Equine Clinic and its staff to hospitalize my horse, administer vaccinations, medications, tests, surgical procedures, anesthetics, or treatments that are deemed necessary for the health, safety, and well-being of the above animal while under their care and supervision. *
Initial
If my horse should injure itself in an escape attempt, refuse food, become ill, or die while in the hospital, I will hold Colorado Equine Clinic and the staff free of any responsibility and/or liability in the absence of gross negligence. *
Initial
I further realize that I am responsible for payment for the indicated procedures and treatments in full at the time the animal is discharged unless other arrangements have been made. If I neglect to pick up the animal within five days of verbal notice that he or she is ready for release, the animal is considered abandoned. Abandonment does not release my obligations to the bill. *
Initial
I agree that in the case of non-payment a finance charge of 1.5% per month (18% annum) will be charged and that any collection fees or attorney fees will be paid by me. *
Initial
Owner Signature *

Clear
Should be Empty:

Hospitalization & Surgical Release Form