Genesee Valley Equine Clinic | Emergency Care/Consent for Treatment Release Form

Emergency Care/Consent for Treatment Release

The veterinarians at Genesee Valley Equine Clinic provide emergency care and perform procedures like dentistry, reproductive examinations, assisted deliveries, wound care, nerve blocks, joint injections, biopsies, vaccinations and diagnostic imaging for horses on a daily basis. All these services carry inherent risks. Sometimes the urgency of the situation prevents the owner from attending the procedure. At other times the owner of the horse may live in a different area or be out of town.We want to give your horses the veterinary attention you want in ANY circumstance.If an emergency arises or an invasive procedure is necessary, we will always try to contact you. We will explain the known risks, give you an estimate of costs, and discuss the prognosis of the situation. In the event that we are unable to reach you, we ask that you complete this release. The release authorizes us to provide veterinary care in your absence and allows you to let us know if there is anything that you do not give us permission to do. THANK YOU!

Name *

First

Last

Horse(s) Name(s) *

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: *

Please write "Not applicable" if you have no exclusions.

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

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

Checkboxes *

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.

Please choose one.

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 *

First

Last

Date Signed *

MM/DD/YYYY

Checkboxes

This form replaces any authorizations previously submitted for my horse(s).

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