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New Client Packet

Veterinary Service Agreement

Horse Name
Type
Breed
Color
Age
Owner Name
ID Number
Address
Street Address City State Zip Code
Daytime Phone Number
- I am the owner or authorized agent for the owner, of the above-described horse and have the requisite authority to execute this consent. I hereby consent and authorize the performance of the following procedure(s) or operation(s):
Reason For Appointment
Date of Appointment
MM slash DD slash YYYY
- I understand that during the performance of the foregoing procedure(s), unforeseen conditions may be revealed that necessitate an extension or different procedure(s) than those set forth above. Therefore, I hereby consent to authorize the performance of such procedure(s) as are deemed necessary and desirable in the exercise of the veterinarian’s professional judgment.
  I authorize the use of appropriate sedation and/or other medication(s) and I understand that hospital support personnel will be utilized as deemed necessary by the veterinarian.
  
  I have been advised as to the nature of the procedure(s) or operation(s) and the risks involved. I acknowledge that the results cannot be guaranteed.
  
  I acknowledge that, in the course of treatment, it may be necessary for the owner, agent of the owner, or an employee of East Coast Equine to ride the above described horse. I hereby authorize and consent to such a ride and I agree to release, indemnify and hold East Coast Equine, its employees, agents, successors, volunteers, or assigns, harmless from and against any and all loss, damage, claim, liability, or responsibility of whatever kind and nature, including court costs and attorney fees, arising from, or incurred in connection with, injuries to myself or other persons or damage to property or to the above described horse which may arise by virtue of my riding or an employee of East Coast Equine riding the above described horse.
  WARNING: UNDER THE NEW JERSEY EQUINE ACTIVITY LIABILITY ACT, EACH PARTICIPANT WHO ENGAGES IN AN EQUINE ACTIVITY EXPRESSLY ASSUMES THE RISKS OF ENGAGING IN AND LEGAL RESPONSIBILITY FOR INJURY, LOSS OR DAMAGE TO PERSONS OR PROPERTY RESULTING FROM THE RISK OR EQUINE ACTIVITIES.
  I further agree that my authorized agent or I will pay all past and current charges on my account. Should I fail to comply with this policy, East Coast Equine is authorized to charge my credit card for the entire balance. I realize that my account is subject to an interest charges on any overdue balances and that I am responsible for all collection costs if this invoice is not paid pursuant to its terms and conditions.