Hospital Admissions Form

AUTHORIZATION FOR PROFESSIONAL SERVICES

TO ADMIT YOUR HORSE TO OUR HOSPITAL THIS FORM WILL NEED TO BE COMPLETED IN ITS ENTIRETY

I certify that I own/have assumed financial responsibility for the above described animal, and I do hereby consent and authorize the Mid-Rivers Equine Centre and its statff to hospitalize this animal and to administer vaccinations, medications, tests, surgical procedures, anesthetics or treatments that the doctors deem necessary for the health, safety and/or well-being of the above horse while it is under their care and supervision.

If this horse should injure itself, refuse food, become ill or die while in the hospital, I will hold the Mid-Rivers Equine Centre free of any responsibility and/or liability in the absence of gross negligence.

PAYMENT TERMS

I further realize I am responsible for payment of the above procedures and treatments in full at the time of discharge. In the event the length of hospitalization exceeds 7 days, we require 80% of the outstanding balance be paid weekly.

In the event that I fail to comply with these terms, I authorize Mid-Rivers Equine Centre to charge the bill in its entirety to my credit card.

Deposit

I understand a deposit will required at the time of admittance. The amount of the deposit will be determined by the hopsital prior to arrival.