Emergency Treatment Guidelines and Consent Form

 

In the event of a veterinary emergency involving your horse, every effort will be made to contact you regarding your horse’s current situation. If however, decisions need to be made and procedures need to be performed in your absence, this form will serve as a GUIDELINE for treatment of your horse.

I. I __________________________, as owner of the horse known as _______________________, stabled at ____________________________________, do give my permission for a veterinarian to perform services on the above named horse in my absence. My preference for a veterinarian is ____________________________________, phone _________________________________. However, if my regular veterinarian is unavailable, ____________________________________ has my permission to call any available veterinarian.

II. The veterinarians may use their best judgment in determining if my horse can be saved within a
reasonable medical probability, quality of life and financial practicality with a cost cap not to exceed $________________. I agree to assume full financial responsibility for these services.

III. My horse IS / IS NOT insured. (If yes, complete the following.)
A. Type of Insurance: ☐ Surgical ☐ Mortality ☐ Major Medical (check all that apply)
B. Name of Insurance Company: _____________________________________________________________________________________
C. Policy # ______________________________________________________________________________________________________
D. Contact Name and Telephone # ___________________________________________________________________________________
_______________________________________________________________________________________________________________

IV. I WOULD / WOULD NOT want my horse referred to ____________________________________________________________________
for emergency treatment or surgery if the veterinarian called to treat my horse, in their professional opinion, concludes that my horse may benefit from this emergency referral. Be advised that, if emergency surgery is elected the following must be considered:
1. Emergency colic surgery and follow up care can cost from $2,500 - $10,000, with an approximate 70% chance of recovery and return to normal function. I ☐ AGREE ☐ DO NOT AGREE to have my horse sent for colic surgery.
2. A minimum of 50% of the estimated cost is usually required by most veterinary clinics upon admission of your horse. In your absence, provisions must be made to provide for this down payment (i.e. credit card, signed check, etc.). 50% of the remaining balance is
due upon discharge of your horse, and any other charges not posted will be due in 30 days.
3. If your horse is insured, the insurance company may require that surgery be attempted. Your insurance company will be contacted prior to departure to determine their requirements.
4. If your horse requires transportation to a vet clinic, it will be provided by ___________________________________________________, phone ___________________________. Reimbursement for this expense will be based on fuel costs plus $_____________________.

V. If the treating veterinarian (with the approval of the insurance company, if insured) determines that my horse cannot be saved due to the severity of the condition and/or financial constraints, I hereby authorize them to euthanize my horse for humane reasons.

VII. Any monies paid by _______________________________________________________________ on your behalf for veterinary and associated services must be reimbursed within 7 days.

VIII. Additional Comments: _________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________

IX. My signature below constitutes legal consent for the conditions as stated on pages 1 and 2.
Owner’s Name (printed): _______________________________________________________ Date: _______________________________
Owner’s Signature: _______________________________________________________________________________________________
Address: ____________________________________________ City, State, Zip: ______________________________________________
Home #: ___________________________________ Cell #: _____________________________ Work #: __________________________
Additional Contact Information
Name: _______________________________________________________________ Relationship: _______________________________
Home #: ___________________________________ Cell #: _____________________________ Work #: __________________________
Financial Type: MC VISA DISC AMEX CC #: ____________________________________________________________________________
Information Name on Card: _______________________________________________ Exp Date: ______/______
Signature: ____________________________________________________________ CCV: _________ Zip Code: ___________________
This form with all information will be placed in a sealed envelope with your name on it and you will sign the back flap so you can tell if it has been opened. The information on this form will only be used in case of emergency and will be safeguarded against theft to the best of my ability.

THE FOLLOWING PERSON(S) HAS PERMISSION TO MAKE DECISIONS ON MY BEHALF UP TO AND INCLUDING EUTHANASIA.

☐ Only call the second person if the first is unreachable.
Name: ________________________________________________________ Relationship: _____________________________________
Home #: ___________________________ Cell #: ___________________________ Work #: ____________________________________
Name: ________________________________________________________ Relationship: _____________________________________
Home #: ___________________________ Cell #: ___________________________ Work #: ____________________________________