*Please call our office to schedule your horse’s arrival prior to filling out this form.

KESMARC New Patient Form

Horse's Registered Name

Nickname/Barn Name

Age

Gender

Breed

Primary Discipline

Reason

Injuries

Farm Name

Arrival Date

When will the horse arrive to KESMARC

YYYY

Owner and Billing

Owner's Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Is the horse Insured

Insurance Name

Insurance Phone Number

(###)

###

####

Veterinarian Information

Referring Veterinarian

Vet Phone Number

(###)

###

####

May we contact them if needed?

Veterinarian Recommendations

What therapy/therapies does your veterinarian recommend your horse do during their stay with us?

Do you have vet reports to send?

Please send reports to vhkesmarc@gmail.com

Diagnostics Done

Do you have a preferred vet to be the attending during your horse's stay with us?

If yes please provide name and clinic

Vaccinations

Please include dates (particularly Flu/Rhino)

Coggins Date

Worming Schedule

Please include last worming date.

Farrier Name

Farrier Phone Number

(###)

###

####

May we contact them if needed?

Last farrier date

Farrier Schedule

Special Instructions for Farrier

Additional Horse Inforamation

Stall Rest and Exercise

Please describe history of stall rest and exercise after injury and time frame of time off.

History of Injury or Injuries

Please give a history of injury or injuries which will be address during the horse's stay at KESMARC.

Other Information

Please share any other details about your horse or your horse's history that you think we should know.

Habits

Please share any habits that we should know about (for examples walk kicking, biting, weaving, issues with blanketing, etc.....)

Allergies

Is your horse allergic to any bedding, medications, specific feeds, or grooming products, etc?

How did you hear about KESMARC?

Who was the first employee you had contact with at KESMARC??

First Name

Last Name

Please be sure to upload any previous scans/reports; you will be redirected to a page to do so following submitting this form.