Welcome! Thank you for taking the time to complete this form. If you need to add an additional horses to your account, please CLICK HERE. Owner Name * First Name Last Name Please select all that apply: * I am an established client I am a new client I am a new client, but TREVS has seen my horse before I am an established client, but I have a horse that TREVS has not seen before Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Would you like email updates and news from TREVS? * Yes No Phone * (###) ### #### Permission to contact via text message YES NO How did you hear about us? Horse's Registered Name Horse's Name (everyday name): * Please select one: * I own this horse. I lease this horse. I partial lease this horse. Location of Patient * Owner's House Boarding/Training Facility Private Residence / Facility Other (please state below) Patient Location: * Address 1 Address 2 City State/Province Zip/Postal Code Country Gate Code: Other Instructions for Facility: Contact Name & Number for Facility Owner * Name & Number Sex * Gelding Mare Stallion Age * Birthdate (if known) Breed * Color * Markings * Please be descriptive (sock, blaze, star etc) Microchip Number (if known) Where does your horse normally live? * Stall number, turn out number, directions of paddock or dry lot etc. Please describe your horse's halter and lead rope for easy findings. * Color, name plate, where it can be found, etc. Is there anything specific that you would like Tumalo Ridge Equine to know about your horse? Name of Previous Veterinarian: * First Name Last Name Clinic Name of Previous Veterinarian * Have you or your previous veterinarian sent Tumalo Ridge Equine your horses medical history notes? * Email is: Team@TumaloRidgeEquine.com Yes No If not, does Tumalo Ridge Equine have authorization to contact your previous veterinarian to obtain medical records? * Yes No I understand that my previous veterinarian may need my authorization to send my horse(s) medical records, and I will be in communication to promptly have them sent to Tumalo Ridge Equine via email. I understand If an owner is not present or personally requesting veterinary care for their horse, we need to have written permission on file to provide this care from third parties (i.e.: emergency contact/boarding facility/trainer). * Keep in mind that if someone requests care for your horse, such as vaccines, and they are not on this list, we will NOT be able to schedule it. Please list the first and last name of EACH individual that you are authorizing to make decisions for your horse(s). I understand 1st Individual: * First Name Last Name Phone * (###) ### #### Relationship to listed horse * Please select one Trainer Assistant Trainer Barn or Facility Owner Barn Manager Friend Spouse Family Member Other 2nd Individual: First Name Last Name Phone (###) ### #### Relationship to listed horse Please select one Trainer Assistant Trainer Barn or Facility Owner Barn Manager Friend Spouse Family Member Other 3rd Individual: First Name Last Name Phone (###) ### #### Relationship to listed horse Please select one Trainer Assistant Trainer Barn or Facility Owner Barn Manager Friend Spouse Family Member Other 4th Individual: First Name Last Name Phone (###) ### #### Relationship to listed horse Please select one Trainer Assistant Trainer Barn or Facility Owner Barn Manager Friend Spouse Family Member Other Who permitted to schedule appointments/request/authorize routine/non-emergency care? * Authorized Individual 1 Authorized Individual 2 Authorized Individual 3 Authorized Individual 4 None of the above Who is permitted to request/authorize EMERGENCY care? * Authorized Individual 1 Authorized Individual 2 Authorized Individual 3 Authorized Individual 4 None of the above Who is permitted to authorize a medical referral? * Authorized Individual 1 Authorized Individual 2 Authorized Individual 3 Authorized Individual 4 None of the above Who is permitted to request/authorize a surgical procedure? * Authorized Individual 1 Authorized Individual 2 Authorized Individual 3 Authorized Individual 4 None of the above Who is permitted to authorize emergency euthanasia? * Authorized Individual 1 Authorized Individual 2 Authorized Individual 3 Authorized Individual 4 None of the above I, the undersigned, do hereby certify that I am the owner or duly authorized agent for the owner of the animal described above and that I do hereby give listed authorized individual permission to make medical decisions for said animal(s). I do hereby give Tumalo Ridge Equine Veterinary Services, LLC and Tyler Newton, DVM and his employees complete authority to examine, prescribe for, or treat said animal. I assume all responsibility for all charges incurred in the care of this animal. I understand that these charges are due at time of service and that a deposit may be required for surgical and advanced dental procedures. I understand that if my authorized individual makes the decision for my animal for emergency euthanasia, I give Tumalo Ridge Equine Veterinary Services, LLC and Tyler Newton DVM and his employees or representative full and complete authority to end of life of the said animal by humane euthanasia. Again, by signing this form I am giving permission to my authorized individual(s) to make decisions for said animal listed above. * Date * MM DD YYYY * I agree to electronically sign this document by typing my name. I hereby authorize Tumalo Ridge Equine Veterinary Services, LLC and Tyler Newton, DVM to examine, prescribe for, or treat the above animal. I assume responsibility for all charges incurred in the care of this animal. I, the undersigned, do hereby certify that I am the owner or duly authorized agent for the owner of the animal described above and that I do hereby give listed authorized individual permission to make medical decisions for said animal(s). I do hereby give Tumalo Ridge Equine Services, LLC and Tyler Newton, DVM and his employees complete authority to examine, prescribe for, or treat said animal. I assume all responsibility for all charges incurred in the care of this animal. I understand that these charges are due at time of service and that a deposit may be required for surgical and advanced dental procedures. I understand that if myself or my authorized individual makes the decision for my animal for emergency euthanasia, I give Tumalo Ridge Equine Veterinary Services, LLC and Tyler Newton, DVM and his employees or representative full and complete authority to end of life of the said animal by humane euthanasia. * Date * MM DD YYYY * I agree to electronically sign this document by typing my name. Thank you for completing this form. If you are needing to add any additional horses, please click here
