TD EQUINE Veterinary Services Agreement

OWNER REGISTRATION

Name(Required)

First Last

Corporation Name

Phone(Required)

Email(Required)

Enter Email Confirm Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Secondary Account Holder

First Last

Phone

Relationship

Authorized Agent

First Last

Phone

Relationship(Required)

CONSENT TO SERVICE

Signing Agent(Required)

First Last

Phone(Required)

Realationship(Required)

Rider

Groom

Trainer

Owner

Authorization(Required)

I hereby authorize TD Equine to provide routine and emergency care to my horse(s)

I authorize the use of appropriate sedation and/or other medication(s) while handling my horse

I authorize my agent to make appointments and order medication for my horse(s) and give them permission to charge such appointments / medication to my account.

Signature

Date(Required)

Comments

This field is for validation purposes and should be left unchanged.