Appointment Sign-In Sheet printable pdf download

Appointment Sign-In Sheet

PO Box 747

Newberry, FL 32669

Phone: 352.331.8434

Fax: 352.332.6552

Erica Lacher, DVM

352.665.8222

Stephanie King, DVM

352.665.9838

Appointment Sign-in Sheet

Address:

City:

State:

Zip:

E-mail address:

Home Phone:

Cell Phone:

Horse Information (extra horses can go on the back):

Name:_______________ Birthday:___________ Breed:________________Sex:_________

Anything you would like us to know about your horse’s specific health needs:

_______________________________________________________________________

Reason for Visit:

Vet your appointment is with: ___________________

Appointment time:

Will you be picking your horse up today? YES NO

What does your horse normally eat?

As the owner/agent for the above named horse(s), I authorized Springhill Equine Veterinary Clinic and their

agents to treat this animal as they deem necessary. I assume responsibility for all charges incurred during the

care of this animal. I further understand that payment is due at the time services are rendered.

Signature:_________________________________________________Date: 8/8/2011

Drivers License:______________________________________Exp:________________________

MC or Visa: ___________________________________________________Exp:__________V code_____

Please answer the following questions so we may serve you and your horse(s) better:

Is your horse taken out around other horses frequently?

Yes

Would you like to have your horse Micro Chipped while here?

Yes

Appointment Sign-In Sheet