Owner Name *

First Name

Last Name

Owner Phone *

(###)

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Date of last Tetanus vaccination *

MM

DD

YYYY

If your horse able to be haltered and handled safely? *

Yes

No

Do you have a safe, to be able to complete the procedure? Preferably a grassy area or an area to put clean straw down. *

Yes

No

Are you able to exercise your horse for 20 minutes, twice daily for the next week? *

Yes

No

Do you have a small, dry area like a 24'x24' stall or paddock/round pen, that your horse is comfortable in, to be able to recover for the first 24 hours post castration? *

Yes

No

Some of the uncommon but potential complications problems associated with this procedure include but are not limited to; severe injury during induction or recovery from anesthesia, post-surgical bleeding, post-surgical infection, anesthetic injury or death, and eventration/evisceration of the intestines through the surgical wound. *

I understand and am aware of the risks

I understand that my horse may exhibit stallion-like behavior for a variable period of time after castration. He will also remain fertile for approximately 45 days after his castration. *

I understand

I acknowledge that I have been made aware of these risks. I acknowledge that post-operative care may be required and will be responsible for updating the veterinary surgeon on patient progress and seeking post-operative veterinary care if needed. I confirm that I have read and understand the castration aftercare document and agree to follow the guidelines. I agree to pay all costs associated with this procedure. If there is no history of a tetanus vaccine being administered by a veterinarian in the previous 6 months, I authorize this to be given at the time of castration at an additional cost. *

First Name

Last Name

I, the undersigned, do hereby certify that I am the owner or duly authorized agent for the owner of the animal described above. I authorize Tumalo Ridge Equine Veterinary Services, LLC, to administer a local anesthetic or a general anesthetic to the above named horse for the purpose of gelding the above named horse as deemed appropriate by the attending veterinary surgeon. If applicable, I confirm that I have notified the insurance company that this procedure will be undertaken. I acknowledge that no surgical procedure is without risk to the animal. I accept all potential surgical and anesthetic risks including any complications that may develop as a result of this procedure and agree to forever release Tumalo Ridge Equine Veterinary Services, LLC and its employees. *

First Name

Last Name

Date

MM

DD

YYYY

I agree to electronically sign this document by typing my name.