Welcome! Thank you for taking the time to complete this form. Please keep in mind that this form needs to be completed in full and returned to TREVS before Dr. Newton can establish care for your horse(s). Please keep in mind that even if you are a current client, we do require a new form if your horse transfers barns, trainers, or we update our forms. Thank you! Owner Name * First Name Last Name Please select all that apply: * I am an established client I am a new client I am a new client but TREVS has seen my horse before I am an established client, but I have a horse that TREVS has not seen before Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Permission to contact via text message YES NO Emergency contact for listed Horse(s) that you own: * Please list all horses at this location that are in your ownership. Number of emergency contact: * (###) ### #### Authorized Individual's Relationship to Owner * Property Owner / Trainer Spouse Friend Other Have you completed our Equine Treatment Authorization Form? * No Yes Do you already have an appointment already scheduled? If so, what is the date? MM DD YYYY How did you hear about us? Horse Name * Horse's Barn Name Please select one: * I own this horse. I lease this horse. I partially lease this horse. Location of Patient * Owner's House Boarding/Training Facility Private Residence / Facility Other (please state below) Patient Location: * Address 1 Address 2 City State/Province Zip/Postal Code Country Gate Code: Contact Name & Number for Facility Owner * Name & Number Sex * Gelding Mare Spayed Mare Stallion Age * Birthdate (if known) Breed * Color * Microchip Number (if known) Markings * Please be descriptive (sock, blaze, star etc) Where does your horse normally live? * Stall number, turn out number, directions of paddock or dry lot. Please describe your horse's halter and lead rope for easy findings. * Color, name plate, where it can be found, etc. Is there anything else you would like Tumalo Ridge Equine to know about your horse? Name of Previous Veterinarian: * First Name Last Name Clinic Name of Previous Veterinarian * Have you or your previous veterinarian sent Tumalo Ridge Equine your horses medical history notes? * Email is: Team@TumaloRidgeEquine.com Yes No If no, does Tumalo Ridge Equine have authorization to contact your previous veterinarian to obtain medical records? * Yes No I understand that my previous veterinarian may need my authorization to send my horse(s) medical records, and I will be in communication to promptly have them sent to Tumalo Ridge Equine via email. I understand If an owner is not present or personally requesting veterinary care for their horse, we need to have written permission on file to provide this care by third parties (ie: boarding facility/trainer). * Keep in mind that if someone requests care for your horse, such as vaccines, and they are not on this list, we will NOT be able to schedule it. Please list first and last name of EACH individual that you are authorizing to make decisions for your horse(s). First Name Last Name Phone Number of 1st individual * (###) ### #### Relationship to listed horse * Trainer Assistant Trainer Barn Owner Barn Manager Other (please list) 2nd Authorized Individual First Name Last Name Phone Number of 2nd individual (###) ### #### Relationship to listed horse Trainer Assistant Trainer Barn Owner Barn Manager Other (please list) 3rd Authorized Individual First Name Last Name Phone Number of 3rd individual (###) ### #### Relationship to listed horse Trainer Assistant Trainer Barn Owner Barn Manager Other (please list) 4th Authorized Individual First Name Last Name Phone Number of 4th individual (###) ### #### Relationship to listed horse * Trainer Assistant Trainer Barn Owner Barn Manager Other (please list) Who is permitted to schedule appointments/request/authorize routine/non-emergency care? * Authorized Individual 1 Authorized Individual 2 Authorized Individual 3 Authorized Individual 4 Who is permitted to request/authorize EMERGENCY care? * Authorized Individual 1 Authorized Individual 2 Authorized Individual 3 Authorized Individual 4 Who is permitted to authorize a medical referral? * Authorized Individual 1 Authorized Individual 2 Authorized Individual 3 Authorized Individual 4 Who is permitted to request/authorize a surgical procedure? * Authorized Individual 1 Authorized Individual 2 Authorized Individual 3 Authorized Individual 4 Who is permitted to authorize emergency euthanasia? * Authorized Individual 1 Authorized Individual 2 Authorized Individual 3 Authorized Individual 4 I, the undersigned, do hereby certify that I am the owner or duly authorized agent for the owner of the animal described above and that I do hereby give listed authorized individual permission to make medical decisions for said animal(s). I do hereby give Tumalo Ridge Equine Services LLC and Tyler Newton, DVM and his employees complete authority to examine, prescribe for, or treat said animal. I assume all responsibility for all charges incurred in the care of this animal. I understand that these charges are due at time of service and that a deposit will be required for surgical and advanced dental procedures. I understand that if my authorized individual makes the decision for my animal for emergency euthanasia, I give Tumalo Ridge Equine, LLC and Tyler Newton DVM and his employees or representative full and complete authority to end of life of the said animal by humane euthanasia. Again, by signing this form I am giving permission to my authorized individual to make decisions for said animal listed above * Date * MM DD YYYY * I agree to electronically sign this document by typing my name. I hereby authorize Tumalo Ridge Equine Veterinary Services, LLC and Tyler Newton, DVM to examine, prescribe for, or treat the above animal. I assume responsibility for all charges incurred in the care of this animal. I, the undersigned, do hereby certify that I am the owner or duly authorized agent for the owner of the animal described above and that I do hereby give listed authorized individual permission to make medical decisions for said animal(s). I do hereby give Tumalo Ridge Equine Services LLC and Tyler Newton, DVM and his employees complete authority to examine, prescribe for, or treat said animal. I assume all responsibility for all charges incurred in the care of this animal. I understand that these charges are due at time of service and that a deposit will be required for surgical and advanced dental procedures. I understand that if myself or my authorized individual makes the decision for my animal for emergency euthanasia, I give Tumalo Ridge Equine, LLC and Tyler Newton DVM and his employees or representative full and complete authority to end of life of the said animal by humane euthanasia. * Date * MM DD YYYY * I agree to electronically sign this document by typing my name. Thank you for completing our form. Please fill out additional forms per horse that you own.
