Hospital Admission Form

Owner Information

Name of owner*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number *

Area CodePhone Number

Additional Contact Name and Number

E-mail*

Date of admission*

MonthDayYear

Referring doctor

Would you like your referring vet to receive discharge instructions?

YesNo

Patient Information

Horse's name*

Breed*

Color

Age*

Sex of horse*

MareGeldingStallion

Previous patient?

YesNo

Is the horse insured?

YesNo

Admission Information

Reason for Admission*

Known Drugs or Other Allergies/Vices*

Current Medications*

Feeding Instructions (Please be specific)*

Turnout Instructions*

I authorize the surgical/medical procedure known as:*

to be performed by Woodside Equine Clinic on:*

owned by:*

I hereby verify that I am the owner (or the owner’s duly authorized agent) of the above described animal, that I have confirmed the accuracy of the information above, and that I give my permission for the necessary procedures to be performed. I will not hold Woodside Equine Clinic or any of its employees, owners, or agents responsible in case of injury and/or death related to any authorized procedures in connection herewith.*

I assume full financial responsibility. I understand that Woodside Equine Clinic's payment policy is payment at time of service. I understand the payment terms and agree to pay all charges and fees in accordance with these terms, regardless of the outcome of treatment. The attending physician will discuss the estimated cost of the (uncomplicated) surgical/medical procedure and hospitalization. *

I understand that upon admission, a 50% deposit is required. The balance is due when the animal is released. I hereby agree to pay for any and all collection fees and/or legal fees incurred on the above said animal.*

Method of payment*

Credit card- Visa, Mastercard, Discover, AMEXCheck or CashCare Credit or John Deere Financial

I have been advised of the procedures to be performed and understand the advantages of treatment, possible complications/risks, associated, as well as alternative therapeutic options. I authorize the use of anesthesia as deemed appropriate and understand the risks. I understand that results cannot be guaranteed.*

In the event that I cannot be reached, I authorize Woodside Equine Clinic to perform additional procedures considered necessary on the basis of findings during the course of hospitalization. *

I understand that Visiting Hours are 10 am to 7 pm Monday through Friday. On holidays and weekends, Visiting Hours are from 9 am to 10 am and 4 pm to 6pm.*

When visiting during normal visiting hours, I will check in with the office and wait to be escorted to the stall. I will then check out with the office upon departure.*

If I visit after normal business hours (M-F 8-5), I will make prior arrangements with the doctor. I will call the number on the sign out front and wait for a staff member to escort me to my horse's stall.*

I understand that I am only permitted to visit my own horse and that contact with any other patient is prohibited. I will not administer any treatments without checking with the attending veterinarian. DIRECT CONTACT WITH ANY HORSES IN ISOLATION IS NOT PERMITTED.*

I understand and agree to all the information listed above. *

Signature*