Low Cost Vaccine Clinic Application

Only vaccines, worming, and microchips will be available at this clinic.

Owner Name *

Owner Address *

City *

State *

Zip Code *

Home Phone

Cell Phone *

"I have received a copy of the equine information sheet and authorization to treat form." *

Initial here

Signature *

Date *

Owner's Name *

Horse's Registered Name *

Horse's Nickname

Breed *

Color *

Sex *

Age or DOB *

Markings *

Is horse insured? *

If Yes, who is your carrier?

Phone Number of Carrier

Please list below any pertinent medical history *

"I authorize treatment of the above horse by Dr. Charlotte Kin, and employees of Exclusively Equine Veterinary Services, PC. I understand that I am fully responsible for the cost of services, and that payment is due at the time services are rendered. I also understand that there are inherent risks and complications to any medical procedure." *

Signature

Date *

Owner's Name (second horse)

Horse's Registered Name (second horse)

Horse's Nickname (second horse)

Breed (second horse)

Color (second horse)

Sex (second horse)

Age or DOB (second horse)

Markings (second horse)

Is horse insured? (second horse)

If Yes, who is your carrier? (second horse)

Phone Number of Carrier (second horse)

Please list below any pertinent medical history (second horse)

Signature

Date (second horse)

Owner's Name (third horse)

Horse's Registered Name (third horse)

Horse's Nickname (third horse)

Breed (third horse)

Color (third horse)

Sex (third horse)

Age or DOB (third horse)

Markings (third horse)

Is horse insured? (third horse)

If Yes, who is your carrier? (third horse)

Phone Number of Carrier (third horse)

Please list below any pertinent medical history (third horse)

Signature

Date (third horse)

Would you like to be contacted by Exclusively Equine after the vaccine clinic to schedule additional treatment/care for your horse(s)? *

Would you like to be contacted by Nexus Equine after the vaccine clinic for information on additional relief/support for your horse(s)? *

Photo/Video Release Form: "I grant permission to Nexus Equine, Inc and their agents and employees the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of me, or members of my family, for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium. I hereby release Nexus Equine, Inc and its legal representatives from all claims and liability relating to said images and/or videos. Furthermore, I grant permission to use my statements that were given or will be given during an interview, with or without my name, for the purpose of advertising and publicity without restriction. I waive my right to any compensation." *

Name

I acknowledge that I am *

Over the age of 18
The legal guardian of the following

If legal guardian of participants, please list name here:

Signature *

Date *

Address *

Phone