Date

MM

DD

YYYY

Name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Barn Address if different from home

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Wellness Plan Horse #1 *

Wellness Plan

Performance Plan

Senior Plan

Wellness Plan Horse #2

Wellness Plan

Performance Plan

Senior Plan

Wellness Plan Horse #3

Wellness Plan

Performance Plan

Senior Plan

Wellness Plan Horse #4

Wellness Plan

Performance Plan

Senior Plan

Wellness Plan Horse #5

Wellness Plan

Performance Plan

Senior Plan

Payment Options *

Payment of the full plan cost will be due at the time of the first wellness visit. Please be aware that Wellness Plans do not include trip charges. We will charge your credit card on file for each visit for trip charges, additional medications, and other services (as applicable). If you bring your horse(s) to our facility, for their wellness appointment, then there is not trip charge.

Visa

Mastercard

Discover

American Express

I understand that by checking the box below and submitting this form, I am authorizing Steele Equine to either charge my credit or debit card or draft my bank account, as I specified above. *