Owner Absence Consent

In the event of a medical emergency involving my animal(s), every effort should be made to contact me regarding my horse's current situation. Below are the phone numbers I can be reached throughout my absence, as well as the names and numbers of those who are caring for my animal(s).

OWNER INFORMATION

Owner's Name*

First Last

Email*

Phone Number*

Caretaker's Name*

First Last

Caretaker's Phone Number*

FROM*

Dates of Absence

TO*

Dates of Absence

HORSE INFORMATION

If decisions need to be made or procedures need to be performed in my absence, this form will be used to make decisions about the following horses

Horse(s) Barn and/or Registered Name(s)*

Barn/Boarding Facility if applicable

Address

Street Address City State / Province / Region ZIP / Postal Code

AUTHORIZATION

permission checkbox*

I give my permission to the veterinarians at Countryside Veterinary Services to perform services on the above named animals in my absence. If the emergency is life threatening, the doctors may use their best judgment in determining if my animal can be saved within a reasonable medical probability and financial practicality

Up to what amount do you authorize services for?

permission checkbox 2*

If the veterinarians at Countryside determine that my animal cannot be saved due to the severity of the condition and/or financial constraints, I hearby authorize Countryside to euthanize my animal for humane reasons.

permission checkbox 3*

I agree to assume full financial responsibility for these services

Signature*

Type Your Name*

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OWNER INFORMATION

HORSE INFORMATION

AUTHORIZATION

Contact Info

Office Hours

Site Links

Owner Absence Consent

OWNER INFORMATION

HORSE INFORMATION

AUTHORIZATION

Contact Info

Office Hours

Site Links

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