New AI & Semen Established Client

ARTIFICIAL REPRODUCTION CONSENT FORM

Established Client
Client Type *

Established
Client/Owner Name *

First Name Last Name
Please Fill in Any Information or Update New Information

Click Here to Add Mare(s)

Mare Information:

	Barn Name	Registered Name	Age	Breed	Color	Insured?	Insurance Company	Vaccinated?	Wormed?
Mare #1

Where is Horse Stabled?
ex: At Home or Farm Name
Is this a Maiden Mare?

Yes No
If No, how many has she had?
Cooled or Frozen Semen?

Cooled Frozen
If Using Cooled Semen:
Stallions Name: *
Where is Stallion Standing? *
Agents Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email *
example@example.com
Or Collection Facility Number:
If Using Frozen Semen:
Name of Stallion: *
Stallion Registration Number or Company: *
Where is Frozen Semen Coming From? *
Phone Number: *

Area Code Phone Number
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How Many Straws? *
Fee Schedule as of January 1st, 2022
Please Select One (1) Option Below
Monthly Storage Fees
- 1 to 20 Doses - $45.00
- 20 to 40 Doses - $55.00
- 40 plus Doses - $60.00
Yearly Storage Fees
- 1 to 20 Doses - $395.00
- 20 to 40 Doses - $550.00
- 40 plus Doses - $650.00
Which Option Best Suits You?

Monthly Yearly
Are You Adding More Than One (1) Mare?

Yes No

Where is Horse Stabled?
ex: At Home or Farm Name
Is this a Maiden Mare?

Yes No
If No, how many has she had?
Cooled or Frozen Semen?

Cooled Frozen
If Using Cooled Semen:
Stallions Name:
Where is Stallion Standing?
Agents Name

First Name Last Name
Phone Number

Area Code Phone Number
Email
example@example.com
Or Collection Facility Number:
If Using Frozen Semen:
Name of Stallion:
Stallion Registration Number or Company:
Where is Frozen Semen Coming From?
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How Many Straws?

Where is Horse Stabled?
ex: At Home or Farm Name
Is this a Maiden Mare?

Yes No
If No, how many has she had?
Cooled or Frozen Semen?

Cooled Frozen
If Using Cooled Semen:
Stallions Name:
Where is Stallion Standing?
Agents Name

First Name Last Name
Phone Number

Area Code Phone Number
Email
example@example.com
Or Collection Facility Number:
If Using Frozen Semen:
Name of Stallion:
Stallion Registration Number or Company:
Where is Frozen Semen Coming From?
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How Many Straws?

Where is Horse Stabled?
ex: At Home or Farm Name
Is this a Maiden Mare?

Yes No
If No, how many has she had?
Cooled or Frozen Semen?

Cooled Frozen
If Using Cooled Semen:
Stallions Name:
Where is Stallion Standing?
Agents Name

First Name Last Name
Phone Number

Area Code Phone Number
Email
example@example.com
Or Collection Facility Number:
If Using Frozen Semen:
Name of Stallion:
Stallion Registration Number or Company:
Where is Frozen Semen Coming From?
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How Many Straws?

Click Here to Add Stallion(s)

Stallion #1

	Barn Name	Registered Name	Age	Breed	Color	Insured?	Insurance Company	Vaccinated?	Wormed?
Stallion #1

Stallion Registration Number:
Where is Horse Stabled?
ex: At Home or Farm Name
What is the Stallion being Collected for?

Cooled Frozen Training
Last tested for EVA:

Month Day Year
Date
*Please Submit a Copy of the Stallion's Registration papers.*
Fee Schedule as of January 1st, 2022
Please Select One (1) Option Below
Monthly Storage Fees
- 1 to 20 Doses - $45.00
- 20 to 40 Doses - $55.00
- 40 plus Doses - $60.00
Yearly Storage Fees
- 1 to 20 Doses - $395.00
- 20 to 40 Doses - $550.00
- 40 plus Doses - $650.00
Which Option Best Suits You?

Monthly Yearly
Are You Adding More Than One (1) Stallion?

Yes No

Stallion Registration Number:
Where is Horse Stabled?
ex: At Home or Farm Name
What is the Stallion being Collected for?

Cooled Frozen Training
Last tested for EVA:

Month Day Year
Date

Stallion Registration Number:
Where is Horse Stabled?
ex: At Home or Farm Name
What is the Stallion being Collected for?

Cooled Frozen Training
Last tested for EVA:

Month Day Year
Date

Stallion Registration Number:
Where is Horse Stabled?
ex: At Home or Farm Name
What is the Stallion being Collected for?

Cooled Frozen Training
Last tested for EVA:

Month Day Year
Date

Click Here to Update Owner Information
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone Number:

Area Code Phone Number
Home Phone Number:

Area Code Phone Number
Work Phone Number:

Area Code Phone Number
Email:
example@example.com
Bills Sent Electronically:

Yes No *service charge will be applied
Horse Stabled at:
Barn Phone Number:

Area Code Phone Number
Referring Vet Name:

First Name Last Name
Referring Vet Phone Number:

Area Code Phone Number
Payment Authorization

Credit card or bank account will be charged if payment is not received within 15 days from receipt of statement.
Payment Preference

Please automatically charge my credit card or bank account on receipt of invoice for all charges incurred (this makes you eligible for a discount on dispensed medications). Pay in full at the time of service using Cash Pay in full at the time of service using check Pay in full at the time of service using Credit Card Pay in full at the time of service using Care Credit/Wells Fargo/ScratchPay

USD Description

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Signature

Clear

Terms & Conditions Frozen Semen Storage
TERMS AND CONDITIONS

This agreement is entered into as of the “Effective Date” noted below, by and between Rhinebeck Equine, L.L.P., 26 Losee Lane, Rhinebeck, NY 12572 (hereinafter “RE”), and the Owner identified on the cover page hereto (“Owner”).

1. RE hereby agrees to store or cause to be stored any and all frozen semen delivered to RE (hereinafter “goods”), subject to the terms of this agreement. Notwithstanding the foregoing, RE reserves the right to reject any goods delivered by Owner, in its sole and absolute discretion, in which case RE will notify Owner that the relevant goods have been rejected and that this agreement does not apply thereto.

2. RE’s shall exercise a reasonable degree of care with respect to the receipt, storage, and disposition of all goods delivered by Owner that are subject to this agreement, subject to the terms and condition set forth herein.

3. Owner acknowledges and agrees that any and all goods accepted by RE pursuant hereto are accepted, and will be stored, in their AS-IS state and condition, without inspection by RE of any kind or nature. Without limiting the generality of the foregoing, Owner acknowledges and agrees that RE DOES NOT GUARANTEE OR WARRANT THE QUALITY, CONDITION, ABILITY TO FERTILIZE, POST-THAW MOTILITY, MORPHOLOGY OR ANY OTHER CHARACTERISTIC OR ASPECT OF ANY GOODS SUBJECT TO THIS AGREEMENT. Rather, ALL WARRANTIES OF EVERY KIND AND NATURE, EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO, WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE, ARE HEREBY DISCLAIMED, and RE shall not be liable therefor in any respect.

4. Owner agrees to pay the fees set forth on the cover page for each month or portion thereof that goods are stored by RE pursuant to this agreement. Such fees are subject to change in RE’s sole and absolute discretion, with or without advance notice to Owner, and the fee charged and due from Owner will be the fee in effect for each month or portion thereof that goods are stored by RE pursuant to this agreement. Any and all fees due in accordance with this Section are due and must be paid no later than the twenty-eighth (28th) day of each month during which goods are stored at RE. Monthly fees due in accordance herewith shall not be pro-rated for any reason, including on termination hereof prior to the end of any month.

5. In addition to the fees due from Owner pursuant to Section 3 above, Owner shall be responsible for and shall pay any and all fees and expenses incurred during the term of this agreement for the removal, shipment or relocation of the goods stored by Owner, which fees and expenses will be charged at RE’s usual and customary rate according to a fee schedule at the time of service. (Owner may request a copy of the fee schedule at any time.) Any and all such fees and expenses are due and must be paid no later than ten (10) days after an invoice therefor is sent to Owner.

6. OWNER GRANTS RE A LIEN ON, AND SECURITY INTEREST IN, ANY AND ALL GOODS SUBJECT TO THIS AGREEMENT AS SECURITY FOR PAYMENT OF ANY AND ALL AMOUNTS DUE FROM OWNER TO RE. If Owner defaults in payment of any amount due hereunder or with respect to any liability or obligation of Owner hereunder or in connection herewith, and such default continues for a period of sixty (60) days, RE shall be entitled to exercise any and all rights and remedies afforded to a (secured) credit under applicable law or in equity including, but not limited to, the right to: (a) remove and destroy any and all goods; (b) remove and transfer any and all goods; and (c) sell any and all goods at public or private sale, to one or more persons, upon no less than ten (10) days written notice of such sale to Owner mailed, postage prepaid, to the address of the Owner set forth on the cover page hereto. Should RE sell the goods, RE will provide an accounting of the sale to Owner, and if there is any surplus resulting from the sale after RE’s recovery of any and all amounts due hereunder plus the costs and expenses of enforcement, collection and/or sale, including, but not limited to, attorneys’ fees incurred in connection therewith, the same shall be paid over to Owner, but if said sale results in a deficiency after RE’s recovery of any and all amounts due hereunder plus the costs and expenses of enforcement, collection and/or sale, including, but not limited to, attorneys’ fees incurred in connection therewith, Owner shall remain and be fully liable for such deficiency.

7. Owner agrees to defend, indemnify, and hold harmless RE, its employees and agents against any and all claims, including third party claims for loss of goods collected under this contract. Owner agrees to assume all risk of loss of goods collected and stored under the terms of this contract and agrees that the Owner is solely responsible for maintaining any and all insurance on all goods delivered to RE in such amounts as the Owner shall deem appropriate and RE shall have no responsibility whatsoever to obtain any insurance on any of the Owner’s goods. All risks, exclusive of risks resulting from the gross negligence of RE, connected with the storage, transportation pursuant to storage, or other transportation at the request of the owner shall be born by the Owner.

8. RE shall employ the degree of care customarily employed by person/entities storing goods and otherwise collecting, freezing, and handling goods in the general location in which the goods is stored and shall not be liable for the loss of or damage to the goods stored unless it is established by the Owner that such degree of care was not provided by RE. Owner also agrees that RE will retain the right to a customary post-thaw evaluation of at least one unit of goods from each collection processed by RE and that collections not fulfilling minimum quality standards will not be commercially distributed without an evaluation statement claiming that RE does not recommend goods from this collection to be used for artificial insemination. RE reserves the right of judgment as to which collections are not worthy of freezing and/or storage.

9. Owner acknowledges that RE makes no guarantee or warranty with respect to the quality, condition, ability to fertilize, post-thaw motility, morphology or any other characteristic of the goods stored pursuant to this Agreement. RE makes no warranty of any kind whatsoever, expressed or implied, which extends beyond a description of the services agreed upon herein, and hereby disclaims all warranties, including warranties of merchantability or fitness for a particular purpose.
10. Jurisdiction and venue for any action to enforce this Contract, or for damages or any other relief arising from or in connection with it, shall originate exclusively in the District Court in and for the County of Columbia, State of New York.

11. This Agreement constitutes the entire agreement among the parties. It supersedes any prior Agreement, written or oral, or any understanding between them, and it may not be modified or amended in any manner other than by a written instrument signed by both parties.
Terms and Conditions
- A fee of $779.50 per COOLED semen 1st cycle or $1,351.50 per FROZEN semen 1st cycle will apply. This fee includes routine medications. Sedation, additional medications and procedures (ex. twin reductions or caslicks procedures) will be charged accordingly. Up to 3 days of board & care at Rhinebeck Equine are included for cooled semen and up to 5 days for frozen semen. Additional board will be charged at $61.00 per day for dry mares or $79.50 per day for wet mares.
All accounts are payable at the time of Patient discharge.

The Owner Acknowledges and Accepts the Following:
- Breeding and rearing of mares is a high risk activity and the owner has the option to insure against such loss.
- Follicle and pregnancy testing involve per rectal examinations, this carries a small but finite risk of injury, infertility, and death.
- Approximately 10% of all pregnancies result in twins, these are routinely managed by early identification and reduction to a single pregnancy, this can occasionally result in the loss of both embryos.
- Reproductive hormones, sedatives, and relaxants will be used at our discretion.
- Rhinebeck Equine accepts no liability for any loss suffered by the owner and the owners shall be solely responsible for all insurance arrangements made for the mare or its progeny.
I have read, understand and agree to accept the terms and conditions herein.
Owners Signature *

Clear
Select the Date this Document is Signed *

Month Day Year
Date

Terms and Conditions Continued
Name

First Name Last Name
Signature

Clear
Date

Month Day Year

Payment Information
All accounts require a credit card or bank account on file even if you will be paying at the time of service. Please check your preferred method of payment and sign below.
Payment Authorization Date

Month Day Year

Hospital Visitation Policy
Hospital Visitation Policy:

*Due to COVID our policy has been adjusted, please contact the hospital first.

We want to provide the best possible care for your horse and for others in our hospital. The following visitation guidelines will help us provide the necessary care to all of our patients.

1. Client may visit once a day, with the duration of visit no more than 30 minutes.
2. Visiting hours are during our hospital’s normal business hours (8 AM – 5 PM, M-F, and 8 AM-12 PM, Saturdays.)
3. Clients are required to check-in at the reception desk prior to visitation.
4. All visitors must be accompanied/observed by a representative of Rhinebeck Equine, LLP for the duration of their visit.
5. In an effort to maintain client/patient confidentiality, visitors are required to restrict their activities to their horse’s location in the hospital only.
6. In an order to provide optimal care and service, changes in these policies may be made at the discretion of the veterinarian(s) or technical staff in attendance and clients are required to comply with their recommendations.
I am the owner of the described horse and have the authority to execute this consent. I hereby authorize Rhinebeck Equine, LLP to examine and if necessary, treat said horse according to the following term and conditions.
Rhinebeck Equine, LLP and its officers, agents and employees will provide such veterinary medical care as they deem reasonable and appropriate under the circumstances.
Rhinebeck Equine, LLP and its officers, agents and employees will use reasonable care in the treatment of the above mention horse, but will not be liable for any loss or accident that may occur or any disease that may develop as a result of the care and treatment provided.
In executing this form, I hereby expressly acknowledge that risks, benefits and alternative forms of treatment have been explained to me, and thus I understand the explanation and consent to treatment. Should any additional treatments or diagnostics be required during the continued care of my horse, I understand that I will be given the opportunity to discuss and consent to these additional procedures. I understand that further or additional treatment may be required without an opportunity for discussion and consideration by me in the case of the development of any emergency during the continued care of my horse and I expressly consent to all such reasonable treatment as required. I realize and understand that results cannot be guaranteed.
I agree to pick up the horse when notified that it is ready for release.
In the event the horse is not picked up and if ten (10) days have expired since a registered letter was sent to the address given notifying me to call for the horse, the horse may be sold or otherwise disposed of in a humane manner and any proceeds from a sale applied to the charges incurred in caring and treating the horse. Failure to remove the horse will not and does not relieve me from obligation for the costs of services rendered. In addition, I understand that in the event the horse dies I am still responsible for all charges incurred.

I, hereby grant Rhinebeck Equine permission to take photographs of myself and/or my horse, and to publish those photographs for any lawful purpose, including, but not limited to, their website, social media accounts, promotional and educational materials, either digital or in print, in perpetuity. I also grant permission to use my name and/or my pet’s name.
Equipment: If any equipment is left with the horse, it will be accepted with the understanding that Rhinebeck Equine, LLP assumes no responsibility for any loss of equipment that may occur. The following equipment has been left with the horse.
Initial here to decline photography permission of your horse and/or yourself
Should be Empty:

ARTIFICIAL REPRODUCTION CONSENT FORM

If Using Cooled Semen:

If Using Frozen Semen:

Fee Schedule as of January 1st, 2022

If Using Cooled Semen:

If Using Frozen Semen:

If Using Cooled Semen:

If Using Frozen Semen:

If Using Cooled Semen:

If Using Frozen Semen:

Fee Schedule as of January 1st, 2022

Payment Authorization