Consent For Treatment Client/Owner Full Name(Required)Address(Required) Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Phone Number(Required)Alternate Phone Number(Required)Patient Information(Required)Horse NameSexBreed Add RemoveDate of Hospital Admission(Required) MM slash DD slash YYYY Reason for Hospital Admission(Required)My Horse will be staying at Charleston Equine for a routine procedure or breeding and Charleston Equine will be responsible for feeding my horse:(Required) Yes No Grain Requirements(Required)Grain TypeGrain AmountGrain Frequency Add RemoveHay Requirements(Required)Hay TypeHay AmountsHay Frequency Add RemoveIs there any other additional information that you would like to provide regarding your horses feeding routine:Additional Feed Cost(Required)I understand that it is my responsibility to provide feed for my horse while they are admitted to Charleston Equine Clinic. I understand that it is my responsibility to provide enough feed for the duration of the stay of my horse. If I do not provide enough feed for the duration of my horses stay with Charleston Equine Clinic, I understand that additional fees may be added to my final hospital bill. I understand and agreeInitial(Required)Date(Required) MM slash DD slash YYYY Hospital Deposit(Required)I, the undersigned owner or agent of the horse identified above, understand that a deposit will be required upon admitting the horse identified above to Charleston Equine Clinic. If after hours, I understand that Charleston Equine Clinic will contact me the following business day to discuss and collect a deposit. A hospital deposit can range from $500-$2500 pending the reason for admission. If I have not been quoted for a deposit by my admitting doctor, I understand that the deposit price will be provided by the office. I agree to the deposit policyInitial(Required)Date(Required) MM slash DD slash YYYY I intend to pay the required hospital deposit via(Required) The Credit or Debit Card held on file with Charleston Equine Clinic A Credit or Debit Card not on file with Charleston Equine Clinic A Care Credit Card Check - To be given in office the same day of admission Cash - To be given in office the same day of admission Please confirm the card information on file:(Required)Last 4 digits of the card on file :Expiration Date of card on file: Add RemovePlease provide the Credit, Debit or Care Credit Card information below:(Required)Card Number :Expiration Date :Card Identification Number: Add RemoveInterventions(Required)In the event that I am unable to be reached and the veterinarians at Charleston Equine Clinic determine that my horse cannot be “saved” due to the severity of the medical condition and/or financial restrictions, I hereby authorize them to euthanize my horse for humane reasons. Yes No Colic Surgery(Required)Is colic surgery a viable option? Yes No Consent(Required)I, the undersigned owner or agent of the horse identified above, certify that I am eighteen years of age or over and authorize the veterinarian(s) at Charleston Equine Clinic to perform the above procedures(s). I understand that some risks always exist with any procedure and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding the procedures to be performed have been answered to my satisfaction. While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I agree to pay a deposit as deemed necessary, assume financial responsibility for the remaining fees, and provide payment via cash, credit card, or check at the time my horse is discharged from the hospital. Should unexpected life-saving emergency care be required, and the hospital staff is unable to reach me, the staff has my permission to provide such treatment and I agree to pay for such services. I have filled out the above form to the best of my ability and have read the consent agreement. I agree to all terms for treatment of my horseSignature(Required)Date(Required) MM slash DD slash YYYY
