Mare CEM Quarantine - Rogue Equine & Companion Animal Clinic

CEM Mare - Primary Form. If shipping multple mares, please complete this form first. Following completion you will be presented with a link for listing additional mares.

Owner's Name*

First Last

Physical Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address (if different, otherwise leave blank)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile Phone Number*

Email*

Enter Email Confirm Email

Agent Name

First Last

Agents Company Name

Agent Phone Number

Agent Email

Preferred Primary Contact: Name*

First Last

Mare Name*

Date of Birth*

In Foal?*

Yes
No
Don't Know

Foal on Side?*

Yes
No
Don't Know

Breed*

Color*

Approximate Height*

Markings*

Examples: Star, strip, snip or blaze; pastern, socks or stocking; brands; scars.

Weight*

Microchip Number (if none or not known, type 0000)*

Hidden

Horse(s) Imported

Mare's Name	Age (yr/mo) or Date of Birth	Mare, mare in foal or mare with foal at side.	Breed	Color	Markings (head, legs, brand?)	Height	Weight	Microchip Number

Please list all horses that will be presented for quarantine.

Preferred Primary Phone Number*

Preferred Primary Contact Email*

Expected or Estimated Landing Date at LAX*

Health and Husbandry Information - Please Indicate which statements ARE TRUE*

Influenza vaccine given within 6 months
Rhinopneumonitis vaccine given within 6 months.
Tetanus vaccine given given within one year.
Grass Hay Preferred.
Alfafa Hay Preferred.
Alfalfa/Grass Combination Preferred
Grain Supplementation (see later under "Add-Ons")

Is Mortality/Major Medical Insurance in place?*

Major Medical and Mortality
Mortality only
No Insurance

Additional information or free text instructions - Please list here.

Consent - Terms of Care*

I agree to terms of care.

Pursuant to this agreement, the Owner/Agent authorizes Rogue Equine Hospital (REH) to exercise control and custody of the horse, and requests REH to provide basic CEM quarantine services, arrange for all state-required CEM cultures, procedures and washings to be performed by a state-approved veterinarian, present the horse for inspection to required state agents, and represent the owner’s interest with the applicable state and federal agencies.

REH will provide standard CEM quarantine for the horse described herein in accordance with state and federal regulations, including all state veterinarian costs and expenses and all private veterinarian costs and expenses associated with standard CEM protocol. A qualified veterinarian routinely inspects all horses upon arrival. This initial health inspection will initiate the CEM quarantine protocol. Any adverse findings of the horse’s condition will be immediately disclosed to the owner.
Mares will be quarantined for approximately 15-20 days, depending on weekends and holidays, and laboratory turnaround time for sample processing.

Add-On Service List*

Additional Hay/Free Fed
REH-CEM Provided Grain as directed
REH-CEM Provided Supplements as directed
Blanketing
Turn Out - Paddock/Outside Pen
Hand Walk
Lounge
Hack
Grooming

** Additional service provided with fee. We will confirm with you the fee before activating/performing the service.

Fee Agreement*

I agree to fees as stated.

Owner agrees to pay a Contract Price of $2750.00 for the quarantine period of one mare and is due and payable before departure. A non-fundable deposit of $1375.00 is due and payable upon acceptance of this signed agreement by Rogue Equine CEM.
Fees include the following services: Daily board, hay, water, individual turnout, unsealing of the trailer and initial inspection made by a State or Federal veterinarian upon arrival, as well as all costs associated with USDA mandated CEM quarantine protocols.

The Contract Price is for standard CEM quarantine protocol only. Any and all extraneous veterinary work, including but not limited to, an extended quarantine period, additional cultures, sedation (if the attending veterinarian deems it necessary for staff or patient safety) or emergency services are not included in the contract price and will be itemized and billed to the Owner. Any Additional Services will be itemized and charged, and will be billed in addition to the above costs for quarantine.
Board up to and including 20 days is included. Beginning with 21st day, daily board rate is charged.
Signer agrees that any dispute regarding non-payment of non-refundable deposit or any other due fee will be resolved in Jackson County, Oregon and will be responsible for both party attorney fees and court cost.

Optional Election for Short Form Quarantine - `Approximately 14 days

I elect Short Form CEM Quarantine AND I understand the inherent risk with such election.

I, the owner or agent elect Short Form CEM Quarantine. In short form, treatment begins immediately following the final culture and submission as apposed to waiting the standard 7 days for official results. Where it is likely and anticipated culture results will be negative, USDA acknowledges this fact and allows immediate commencement of standard CEM treatment following the final sampling. Risk does exist in the the form of 1) sample loss by carrier, 2) sample destruction by carrier, 3) sample loss by lab, 4) sample rejection by lab, 5) culture rendered null and void by lab for any reason. While rare, any of the above could occur, including any adverse event not listed. If an adverse event were to occur, CEM quarantine/culture must restart following 7 days of the last treatment, resulting in additional lab fees, shipping and board. Owner/agent agrees to NOT hold Rogue Equine CEM liable and responsible in any form should any adverse event occur following selection of "Short Form CEM Quarantine".

Release of Liability*

I agree to release Rogue Equine Hospital of Liability as stated below

The Owner hereby agrees to release and to hold harmless Rogue Equine Hospital, their agents, employees, officers, directors, owners, and representatives against any and all liabilities, claims, damages, actions, suits or causes of action arising out of or associated with any injury, loss, death or property damage sustained by Owner, its principals, owners, directors, agents, officers, employees, representatives or any third parties, including but not limited to veterinarians, farriers, equine professionals, guests or invitees on the premises at the direction or request of Owner.
The owner acknowledges and understands that it is the owner’s sole responsibility to insure the horse for injury or death, and the owner further acknowledges that REH is not responsible for insuring the horse in any capacity.

Indemnification*

I agree to indemnify Rogue Equine Hospital as stated below

The Owner hereby agrees to indemnify and to hold harmless Rogue Equine Hospital against any and all liabilities, claims, damages, losses, and expenses which Owner may incur or be required to pay should any claim be brought by a third party as a result of any act, intentional or negligent, or omission on part of the Owner in connection with the use and enjoyment of this facility under the terms of this agreement. Owner agrees to defend Rogue Equine Hospital in any action, suit or proceeding brought by any other party based upon or related to any activities involving the horse herein described while horse was in the custody and under the care of Rogue Equine Hospital, or involving a party who has sustained damage to property caused by horse while horse was in the custody and under the care of Rogue Equine Hospital, whether or not such injury or damage was sustained through no negligence of Rogue Equine Hospital, its employees, agents, owners, or directors. It is hereby agreed that Owner must be given notice of a claim relating to any action relating to horse and the terms of this agreement in a timely manner.

Visitation Policy*

I agree to Rogue Equine CEM visitation policy as stated below

All visitors of quarantined horses must comply with the regulations of the Rogue Equine Quarantine Facility and the restrictions in place due to the CEM Quarantine protocol. For the safety and respect of all owners and horses in the facility, visitors must be accompanied by authorized personnel.
Visiting hours are Monday – Friday, 9am-5pm, and by appointment only.
Duration may be limited to availability of authorized personnel.

A deposit for 50% of the contract price is due prior to the horse’s arrival at the CEM quarantine facility. For mares this value is $1375.00. Payment for the remainder of the contract price, and costs for any additional services provided is due BEFORE the horse is released from quarantine. All balances must be paid in full prior to the horse’s departure. The preferred payment method is Wire Transfer. We will forward wire transfer instructions upon return of this form. Credit Cards as method of payment is accepted - we will alternatively send you a credit card authorization form. Please note a 3% transaction fee will be applied to credit card payments.*

I will pay by Wire Transfer and without transaction fee
I will pay by Credit Card and accept a 3% transaction fee

Signature*

Date*

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Name

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CEM Quarantine - Mare

CEM Mare - Primary Form. If shipping multple mares, please complete this form first. Following completion you will be presented with a link for listing additional mares.

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