General Consent Form Equine - Rogue Equine & Companion Animal Clinic

Owners First and Last Names*

First Last

Mobile Phone Number*

Animals Name*

Animals Age*

Sex*

Colt/Stallion
Gelding
Filly/Mare

Breed*

Color*

Hidden

Weight

Recommended test, treatment and or procedure recommended by staff or veterinarian. Please write in.*

Laboratory Testing*

Accept
Decline
Not Applicable

Additional lab testing may be recommended, depending on the procedure. Examples include blood chemistry, CBC, etc.

Comments or requests?*

Please note here if you have any comments or special requests. Please write "none" if you do not have any.

Estimate to be provided before procedure?*

An estimate is requested
An estimate is NOT requested

An estimate will be provided, before commencing procedure, if this choice is selected. A signed/accepted return copy is required.

Agreement/Consent*

I AGREE AND CONSENT

I consent and agree to the services recommended to and listed by me, above. I understand there are additional charges for services as listed. While a verbal estimate should be requested and typically provided, by ticking this box and signing below I decline a written estimate unless already provided in advance for the above listed recommended tests, procedures or treatments. Payment is due at the time of services, or upon presentation of an invoice/statement. In some cases, an estimate may be presented for payment in advance. In all cases, I, the owner or agent, and that person signing this form is responsible for payment. In addition, I understand and agree that in the event of default I may be subject to additional collection and/or attorney's fees when applicable. All disputes to be resolved in Jackson County, Oregon.

Date of agreement and consent*

Signature*

Sign with finger if mobile phone or tablet, drag mouse if PC or Mac.

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

for compassionate, personalized, expert veterinary medical care
serving Southern Oregon and Northern California.

General Consent Form - Equine