3rd Party Medical Consent In the event of a veterinary emergency we will attempt to make contact regarding your horse’s current situation. If we are unable make contact and medical decisions need to be make in your absence, this form will serve as a GUIDELINE for the treatment. Add Additional Horses 1 Horse 2 Horses 3 Horses 4 Horses 5 Horses 1. Horse Name Registration # InsuredYesNoInsurance Company Policy Number Type Mortality Surgical Major Medical 2. Horse Name Registration # InsuredYesNoInsurance Company Policy Number Type Mortality Surgical Major Medical 3. Horse Name Registration # InsuredYesNoInsurance Company Policy Number Type Mortality Surgical Major Medical 4. Horse Name Registration # InsuredYesNoInsurance Company Policy Number Type Mortality Surgical Major Medical 5. Horse Name Registration # InsuredYesNoInsurance Company Policy Number Type Mortality Surgical Major Medical I, as the owner of the horse(s) listed above, give my permission for the veterinarians of Mid-Rivers Equine Centre to perform services on the above named horse(s) in my absence. I appoint the following person to make medical decisions regarding my horse’s care in the event that I am unreachable.Authorized Person* From This Date* MM slash DD slash YYYY To This Date* MM slash DD slash YYYY Cost CapThe doctors may use their best judgment in determining if my horse(s) can be saved within a reasonable medical probability and financial practicality with a cost cap of I agree to assume full financial responsibility for these services.Financial ArrangementsI HAVE or HAVE NOT contacted Mid-Rivers Equine Centre to make financial arrangements in case of emergency. Have Have Not HospitalizationI WOULD or WOULD NOT want my horse hospitalized if necessary for emergency treatment or surgery if the veterinarians of Mid-Rivers Equine Centre, in their professional opinion, conclude that my horse would benefit from this emergency hospitalization. Would Would Not Be advised that if emergency hospitalization or surgery is elected, the following must be considered: Medical treatment of colic with hospitalization and intravenous fluids typically costs approximately $1800-2000 per day. Emergency colic surgery and follow up care can cost from $8,000-12,000. A minimum of a 50% deposit is required by Mid-Rivers Equine Centre at admission. In your absence, provisions must be made in advance with either Mid- Rivers Equine Centre or your horse’s caretaker to provide for this down payment (i.e., credit card number, signed check, etc.). The remaining balance is due upon discharge of horse. If a horse is insured for mortality, the insurance company may require that surgery be attempted, if appropriate, before a claim will be rewarded. Please check the policy and be aware of this. If the doctors of Mid-Rivers Equine Centre determine that my horse cannot be saved due to the severity of the condition and/or financial constraints, I hereby authorize them to euthanize my horse for humane reasons. Efforts will be made to make contact in the event of an emergency. Please leave phone numbers where we can reach with any emergency. Additional Comments/InstructionsHorse Owner* First Last Email* Phone*Date* MM slash DD slash YYYY CAPTCHA