Rental Application

In the event of a medical emergency involving my animal(s), every effort should be made to contact me regarding my horse's current situation. Below are the phone numbers where I can be reached throughout my absence, as well as the names and numbers of those who are caring for my animal(s).

Date of absence:

Owner's Name

First NameLast Name

E-mail

Cell Number

Area CodePhone Number

Home Number

Area CodePhone Number

Caretaker's Name

First NameLast Name

Phone Number

Area CodePhone Number

Address of Boarding Facility

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

If decisions need to be made or procedures need to be performed in my absence, this form will be used to make decisions about the following horses (please include barn name and registered name).

I give my permission to the veterinarians at Countryside Veterinary Services to perform services on the above named animals in my absence. If the emergency is life threatening, the doctors may use their best judgment in determining if my animal can be saved within a reasonable medical probability and financial practicality with a cost cap of:

If the veterinarians at Countryside determine that my animal cannot be saved due to the severity of the condition and/or financial constraints, I hearby authorize Countryside to euthanize my animal for humane reasons.

I agree to assume full financial responsibility for these services.

Signature

Owner Absence Consent Form