Date *

Owner Name *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone Number *

Email *

Horse's Name *

Breed *

Sex *

Age *

Color *

Procedure to be Performed *

Consent:

I, being responsible for the described animal on this form, have the authority to grant consent for said animal to receive treatment, be prescribed medications, or have surgical/medical procedure performed, as deemed necessary.

I hereby give my consent for this patient to receive medical treatment from Vitality Veterinary Services.

Vitality Veterinary Services will use all reasonable precautions against injury, escape, or death but will not be held liable or responsible in any manner in connection therewith as it is thoroughly understood that I assume all risks. I understand that this treatment/operation is necessary. Its advantages, possible complications, and possible alternative modes of treatment have been discussed with me. I understand that further procedures may be therapeutically necessary based on findings during the procedure/surgery, I consent to those procedures, their additional cost, and any unexpected lifesaving emergency care deemed necessary by the attending veterinarian.

Authorization: *

I authorize the use of appropriate sedation and/or medications. I understand that risks and potential complications exist with anesthesia that could involve serious bodily injury, loss of pregnancy, or death.
I understand during the performance of the foregoing procedure or operation, unforeseen conditions may be revealed that necessitate an extension of or different procedures. I hereby consent to and authorize the performance of such procedures or operations as deemed necessary and advisable in the professional judgement of the veterinarian.
I agree to care, custody and handling of my horse by Vitality Veterinary Services. I acknowledge that any inpatient horse is at risk of exposure to pathogens or infectious disease. I acknowledge that Vitality Veterinary Services utilizes measures to prevent such occurrence and hold them harmless against any and all liability attached.

Acknowledgment *

I acknowledge and understand that the procedure, its consequences, and subsequent risks have been explained to me, and I have addressed any questions or concerns I may have. I understand that results cannot be guaranteed.

Insured Patients

If the patient is insured, I agree that it is my responsibility to notify the insurance company as required by the terms of this policy. If the insurance company or adjuster should request information from Vitality Veterinary Services, I authorize release of the patient record for the purpose of processing each claim. If insured, please mark type of coverage: *

Name of Company *

Other

I understand and agree with the terms of this agreement, “Clinic Consent Form,” and fully understand its terms. I intend my signature to be authorization and consent for Vitality Veterinary Services to examine, prescribe, treat, and perform necessary treatment, surgical procedures, and/or anesthesia on the patient listed above. I agree to indemnify and hold Vitality Veterinary Services and their veterinarians and/or staff harmless from and against any and all liability arising out of these procedures.

Signature of Legal Owner *

Clear Signature

Date *

New clinic location coming Spring 2025

Equine Anesthesia/Treatment Consent Form