AVC Equine Emergency Consent Form

Fill out this digital form and hit submit or download the form at the bottom for printing!

In the event of a medical emergency involving my animal (s), every effort should be made to contact me regarding my pet’s current situation. To facilitate, here are the phone numbers where I can be reached throughout my vacation/leave, as well as the people watching my animal (s).

Contact Number

Caretaker’s Name & Number

2nd Contact Number

2nd Caretaker’s Name & Number

If, however, decisions need to be made or procedures need to be performed in my absence, please use this form as a guideline.

the owner of the following:

(Please include registered names and nick names)

who are boarded at

do give my permission for the veterinarians of Adobe Veterinary Center to perform services on the above named animals in my absence.

If the emergency is more severe, the doctors may use their best judgment in determining if my animal can be saved within a reasonable medical probability and financial practicality with a cost cap of $ (Per Animal)

I agree to assume full financial responsibility for these services.

My animal is insuredis not insured.

If yes, it is under the following type (s) of insurance: MortalitySurgicalMajor Medical

Name of Insurance Company:

Policy #

Contact name and telephone number:

Policy requirements on when to contact the insurance company:

would

would not want my animal referred to a secondary facility for emergency treatment or surgery if the doctors at Adobe Veterinary Center, in their professional opinion, conclude that my animal may benefit from this emergency referral. If emergency referral surgery is needed, I understand the following:

1. Emergency equine colic surgery and uncomplicated follow-up can range from $8,000.00 to $15,000.00.

2. Different secondary facilities have different monetary requirements upon admission, and I have made provisions with my animal’s sitter to provide for these requirements.

3. I have made prior arrangements for transporting my animal to the secondary facility of my choice. Name of Transporter:

Telephone Number: In the event that my preferred transporter cannot be reached, I give my permission to Adobe Veterinary Center to attempt to contact another suitable hauler and will assume this financial obligation as well.

4. My insurance company doesdoes not require that surgery be attempted.

If the doctors of Adobe Veterinary Center or the secondary facility determine that my animal can not be saved due to the severity of the condition and /or financial constraints, I hereby authorize them to euthanize my animal for humane reasons.

Additional Comments:

Signature

Date

Print Name of Owner

About Us

Equine Services

Livestock Services

Small Animal Services

AVC Equine Emergency Consent Form

(For Existing Clients Only)

About Us

Equine Services

Livestock Services

Small Animal Services