Client Name *

First Name

Last Name

Client Phone *

(###)

###

####

Client Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Authorized Individual for Listed Horse *

First Name

Last Name

My Authorized Individual is authorized to make these decisions for ALL horses that I own: *

Yes

No

Is this individual permitted to schedule appointments/request/authorize routine/non-emergency care? *

Yes

No

Is this individual permitted to request/authorize EMERGENCY care? *

Yes

No

Is this Individual permitted to authorize a medical referral? *

Yes

No

Is this individual permitted to authorize a surgical procedure? *

Yes

No

Is this individual permitted to authorize emergency euthanasia? *

Yes

No

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 will 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, 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 to make decisions for said animal listed above. *

First Name

Last Name

Date *

MM

DD

YYYY

*

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