PRE REGISTER YOUR HORSE In an effort to ensure our clients enjoy a swift and efficient visit at Stone Ridge Equine Care we have provided a pre registration form for your horse. Clients may complete the form fields listed below and simply click submit. 24 Hour Emergency Equine Services Available For emergency veterinary services outside of our office hours please call the number below and one of our Doctors will be in touch as soon as possible (812) 867-7330 | INFO@SREC40.COM 40 E. BOONVILLE NEW HARMONY RD. | EVANSVILLE INDIANA 47725 Submit Client Registration Form Online Simply complete the fields below and submit. Web Site Responsible Party Email Home Ph. Cell Ph. Address City, State, Zip Code Driver's Lic. # Employer Employer Ph. Employer Address Employer: City, State, Zip Spouse's Full Name Spouse's Email Cell Ph. Number of Horses * ONE TWO THREE FOUR Horse Name (1) DOB or Age Horse Sex Horse Sex STALLION GELDING MARE Breed / Color ALL PAYMENT IS DUE AT TIME OF SERVICES Please Indicate Payment Method * Please Indicate Payment Method CASH PERSONAL CHECK CREDIT CARD CARE CREDIT Payment in FULL is due the day of service for outpatient services. All surgical and intensive care cases require a $500.00 deposit and the balance must be paid in full when the horse goes home. FINANCIAL RESPONSIBILITY AGREEMENT payment disclosure I have read, understand and agree to the terms of the Stone Ridge Equine Clinic's Financial Responsibility Agreement listed below. I understand that I am responsible for all charges for the care of my horse(s) provided by Stone Ridge Equine Care, LLC. I understand a finance charge of 2.00% monthly, (24% Annual Percentage Rate) will be charged on any past due balance should the account become 30 days delinquent. I understand a $40.00 fee will be assessed for any returned checks and added to the account. I understand that if any unpaid balance is assigned to a third party collection agency for collection or placed with an attorney to obtain judgment or otherwise satisfy payment of my account a collection fee of 35% will be added to my account. I agree to pay that fee. I further agree to pay reasonable attorney fees and court costs. I understand and agree to the above terms.