Charleston Equine Clinic

(843) 875-5133

122 Kay Lane, Summerville, SC 29483

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Consent for treatment

Consent For Treatment

Address(Required)
Patient Information(Required)
Horse Name
Sex
Breed
 
MM slash DD slash YYYY
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)
Grain Requirements(Required)
Grain Type
Grain Amount
Grain Frequency
 
Hay Requirements(Required)
Hay Type
Hay Amounts
Hay Frequency
 
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.
Clear Signature
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.
Clear Signature
MM slash DD slash YYYY
I intend to pay the required hospital deposit via(Required)
Please confirm the card information on file:(Required)
Last 4 digits of the card on file :
Expiration Date of card on file:
 
Please provide the Credit, Debit or Care Credit Card information below:(Required)
Card Number :
Expiration Date :
Card Identification Number:
 
Interventions(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.
Colic Surgery(Required)
Is colic surgery a viable option?
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.
Clear Signature
MM slash DD slash YYYY
Request Your Appointment Today!
(843) 875-5133
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Office Hours

Monday – Friday: 8:30am-5:00pm
Saturday, Sunday: Office Closed
Available 24 hours, 7 days a week for equine medical emergencies!

Appointments

We will do our best to accommodate your busy schedule. Request an appointment today!

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(843) 875-5133

122 Kay Lane
Summerville, SC 29483

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