Today's Date

Name

Trainer/Agent or Spouse Name

Email Address

Street Address

City

State

Zip Code

Phone

Driver's License Number

Driver's License State

Address where horse is located

City

Name of farm manager, if not you:

Gate Code

Horse's Registered Name

Gender Gender Mare Gelding Stallion

Horse's date of birth

Color

Any tattoos or brands?

Please select all vaccines that your horse has received within the last 6 months Please select all vaccines that your horse has received within the last 6 months EWT West Nile Flu Rhino Leptospirosis Rabies None

Do you have more than one horse? Do you have more than one horse? No Yes (we will get their info from you later on)

Credit Card Type Credit Card Type Visa MC Discover Amex Debit Card

Card number

Expiration Date

Security Code

Name on Card

Billing ZIP Code

Agreement. Each box must be checked to indicate your agreement to our policies Agreement. Each box must be checked to indicate your agreement to our policies I, the undersigned owner of or owner's agent, hereby authorize Whitney VanWinkle, VMD of Gulf Coast Equine Veterinary Services, Inc. to perform veterinary services on my horse(s). My agreement to pay for veterinary care is implied upon my calling to schedule an appointment for routine medical/surgical care or for emergency services. I understand that payment is due at the time of service. Credit will be extended and services billed with prior approval. In these cases the account is payable in full within 30 days. Accounts not paid in full will be charged interest of 1.5% per month on the balance and any additional services will have to be charged to a credit card or paid in advance. I understand that if any legal action is necessary to collect unpaid invoices, all costs of collection will be charged to the debtor/owner. I understand and acknowledge that payment is due at the time of service in the form of Cash, Check, or Credit Card

Type Full Name as Electronic Signature