POPLAR CREEK HORSE CENTER LLC
Multiple Horse Information
CONTACT INFORMATION:
Name______
Address______
City______State______Zip______
Email address______
Phone numbers:
Home #______Alternate Contact:______
Cell #______Alt. Cont. Ph. #______
Work #______Alt. Cont. Other #______
Other #’s______
HORSE INFORMATION:
(list horse’s barn name and/or registered name)
Horse 1 ______Stall # ______
Arrival Date ______Departure Date ______
Date of last de-worming ______Date of last Coggins test ______
Vaccination record (record dates):
Flu______Tetanus______
Rhino______Strep (Strangles)______
E/W Enceph______Rabies______
West Nile ______Other______
Potomac H.F.______Other______
Horse 2 ______Stall # ______
Arrival Date ______Departure Date ______
Date of last de-worming ______Date of last Coggins test ______
Vaccination record (record dates):
Flu______Tetanus______
Rhino______Strep (Strangles)______
E/W Enceph______Rabies______
West Nile ______Other______
Potomac H.F.______Other______
Horse 3 ______Stall # ______
Arrival Date ______Departure Date ______
Date of last de-worming ______Date of last Coggins test ______
Vaccination record (record dates):
Flu______Tetanus______
Rhino______Strep (Strangles)______
E/W Enceph______Rabies______
West Nile ______Other______
Potomac H.F.______Other______
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Horse 4 ______Stall # ______
Arrival Date ______Departure Date ______
Date of last de-worming ______Date of last Coggins test ______
Vaccination record (record dates):
Flu______Tetanus______
Rhino______Strep (Strangles)______
E/W Enceph______Rabies______
West Nile ______Other______
Potomac H.F.______Other______
Horse 5 ______Stall # ______
Arrival Date ______Departure Date ______
Date of last de-worming ______Date of last Coggins test ______
Vaccination record (record dates):
Flu______Tetanus______
Rhino______Strep (Strangles)______
E/W Enceph______Rabies______
West Nile ______Other______
Potomac H.F.______Other______
Horse 6 ______Stall # ______
Arrival Date ______Departure Date ______
Date of last de-worming ______Date of last Coggins test ______
Vaccination record (record dates):
Flu______Tetanus______
Rhino______Strep (Strangles)______
E/W Enceph______Rabies______
West Nile ______Other______
Potomac H.F.______Other______
Horse 7 ______Stall # ______
Arrival Date ______Departure Date ______
Date of last de-worming ______Date of last Coggins test ______
Vaccination record (record dates):
Flu______Tetanus______
Rhino______Strep (Strangles)______
E/W Enceph______Rabies______
West Nile ______Other______
Potomac H.F.______Other______
Horse 8 ______Stall # ______
Arrival Date ______Departure Date ______
Date of last de-worming ______Date of last Coggins test ______
Vaccination record (record dates):
Flu______Tetanus______
Rhino______Strep (Strangles)______
E/W Enceph______Rabies______
West Nile ______Other______
Potomac H.F.______Other______
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Are any of the horses insured? Yes______No______
Name of Horse ______
Owner of Horse ______
Mortality? Yes______No______Major Medical? Yes______No______
Insurance company______
Phone #______
Policy #______
First choice Veterinarian:______
Office #______Cell #______
Second choice Veterinarian:______
Office #______Cell #______
Preferred Equine Hospital:______
Phone #______City & State______
NOTE: If the listed horse below sustains colic, sickness or injury that requires immediate professional attention from either a local veterinarian and/or state equine clinic, Poplar Creek Horse Center LLC has the signed agreement from the trainer &/or owner, to get the medical attention needed if the owner cannot be contacted. The trainer &/or owner is responsible and agrees to pay all veterinary and hauling expenses.
Horse 1 ______
Horse 2 ______
Horse 3 ______
Horse 4 ______
Horse 5 ______
Horse 6 ______
Horse 7 ______
Horse 8 ______
SIGN HERE______DATE______
Additional notes:
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