Owner Name
*
First Name
Last Name
Please select all that apply:
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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?
*
Phone
*
(###)
###
####
Permission to contact via text message
How did you hear about us?
Horse's Registered Name
Horse's Name (everyday name):
*
Please select one:
*
Location of Patient
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Owner's House
Boarding/Training Facility
Private Residence / Facility
Other (please state below)
Patient Location:
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Gate Code:
Other Instructions for Facility:
Sex
*
Gelding
Mare
Stallion
Age
*
Birthdate (if known)
Breed
*
Color
*
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
If not, does Tumalo Ridge Equine have authorization to contact your previous veterinarian to obtain medical records?
*
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.
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).
1st Individual:
*
First Name
Last Name
Phone
*
(###)
###
####
2nd Individual:
First Name
Last Name
Phone
(###)
###
####
3rd Individual:
First Name
Last Name
Phone
(###)
###
####
4th Individual:
First Name
Last Name
Phone
(###)
###
####
Who permitted to schedule appointments/request/authorize routine/non-emergency care?
*
Who is permitted to request/authorize EMERGENCY care?
*
Who is permitted to authorize a medical referral?
*
Who is permitted to request/authorize a surgical procedure?
*
Who is permitted to authorize emergency euthanasia?
*
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 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
*
