Owner Absence Consent Form at Countryside Vets

Owner Absence Consent Form

In the event of a medical emergency involving my animal(s), every effort should be made to contact me regarding my horse's current situation. Below are the phone numbers I can be reached throughout my absence, as well as the names and numbers of those who are caring for my animal(s).

* Fields marked with an * are required.

owner information

Owners Name*

Email Address*

Phone Number*

Caretaker's Name*

Caretaker's Phone Number*

Dates of Absence *

FROM:

TO:

horse information

If decisions need to be made or procedures need to be performed in my absence, this form will be used to make decisions about the following horses*

Horse(s) Barn
and/or
Registered Name(s)*

Barn/Boarding Facility
if applicable

Street Address

City

State

Zip

authorization

*I give my permission to the veterinarians at Countryside Veterinary Services to perform services on the above named animals in my absence. If the emergency is life threatening, the doctors may use their best judgment in determining if my animal can be saved within a reasonable medical probability and financial practicality

Up to what amount do you authorize services for?

*If the veterinarians at Countryside determine that my animal cannot be saved due to the severity of the condition and/or financial constraints, I hearby authorize Countryside to euthanize my animal for humane reasons.*I agree to assume full financial responsibility for these services

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Online Patient Forms

Owner Absence Consent Form

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