Genesee Valley Equine Clinic | Client Consent for Emergency and Routine Services

Name *

First

Last

Horse(s) Names (please include all horses) *

Barn Name and Location

In the event of an emergency, I authorize the clinic and doctors of Genesee Valley Equine Clinic to administer whatever care and/or medications necessary to treat my horse(s), with the exclusion of the following: *

I appoint the following individual(s) as an authorized representative(s) to make treatment decisions in my absence: *

Phone number for the authorized representative:

I will assume full responsibility for payment of all veterinary services rendered. I authorize services/care/medications up to this monetary limit per horse: *

Authorization to Schedule Appointments - I grant the following permission regarding scheduling veterinary services in my absence: *

Please list full names and relationship to client. If same as above, you can indicate it as such.

Approval for Appointments Specifics: *

Authorized Individual(s) may schedule routine wellness care (vaccinations, deworming, Coggins, dentistry, lameness examinations, etc.).
Authorized Individual(s) may schedule urgent/emergency care if I am not immediately reachable.
I do not authorize scheduling of appointments by anyone other than myself.

Limitations - Please specify any restrictions on the above permissions

Authorization to Release Records - I hereby authorize Genesee Valley Equine Clinic to release routine medical records for the horse(s) listed above to the following individual(s): *

Please include person's full name and relationship to client.

Records Access Permitted (check all that apply): *

Duration of Consent - This authorization will remain in effect until: *

This form is in effect from the date signed, with no end date. I authorize this release to be valid for future services, thus preventing the need for additional signatures.
I authorize this form to be valid for any horses that I purchase in the future.
This form is in only in effect from the dates specified below.

This form is only in effect during this date range. (MM/DD/YYYY - MM/DD/YYYY)

Only applicable if the third option above was selected.

Electronic Signature Acknowledgement - I understand that I am financially responsible for all services rendered and that my authorization does not release me from such responsibility. *

Please type your full name.

Date Signed *

This form replaces any authorizations previously submitted.

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