CommentsThis field is for validation purposes and should be left unchanged.Client Name*Phone*Equine InformationEquine Name*Breed*Color*DOB/Age*Sex* Male Stud Gelding Equine Medical HistoryPlease complete to best of your knowledge. Indicate date of last vaccinationsWest NileTetanusRabiesEast/West EncephalomyelitisRhinopneumonitisInfluenzaFecal FloatDewormingDental ExamCogginsDoes your equine show signs of illness or lameness today?* Yes No Is your pet currently taking any medications?* Yes No Please list previous surgeries or injections:Has your pet had any previous reactions to anesthesia or sedation?* Yes No Do you have additional equines?* Yes No Treatment & Financial Authorization-Please read and check off each statement below: I verify I am the owner (or authorized agent for the owner) of the above-named equine.* I verify I am the owner I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that clinic personnel will be employed in the procedure(s) as directed by the veterinarian. High Prairie Veterinary Service (HPVS) will use all reasonable precautions against injury, death, or escape of my equine.* I authorize the use of anesthesia and other medication I accept the risk inherent in any anesthesia or surgery and release HPVS of any liability associated with the procedure. I further understand that there may be additional, deemed necessary, treatment or expenses upon further examination and commencement ofmy equine’streatment plan. If my equinehas fleas, ticks, mites, or internal parasites, Iunderstand that I will be charged with the cost of removing them.* I accept the risk Signature of Owner
