Permission to Provide Services
Pacific Crest Equine Veterinary Services
In the event of a medical emergency involving my equine(s) every effort should be made to contact me regarding my equine(s) current situation. Below are the phone numbers where I can be reached throughout my absence, as well as the names and phone numbers of those who are authorized to make decisions regarding my equine(s) care if I am unable to be reached. (If you do not authorize anyone, leave blank) I have completed this entire form which clearly indicates my preferences should I not be able to, for any reason, answer my phone. ** Pacific Crest Equine Veterinary Services LLC is also referred to as PCEVS on this form**
Owner Name
First Name
Last Name
Preferred Contact Number
Please enter a valid phone number.
Alternate Contact Number
Please enter a valid phone number.
Email
example@example.com
Caretaker/Authorized Representative
First Name
Last Name
Cartetaker/Authorized Representative Contact Number
Please enter a valid phone number.
Will caretaker/authorized representative have access to a trailer for hauling purposes in the event of an emergency?
Please Select
Yes
No
Horse's Name
Horse's Age
Horse's Breed
Horse's Color & Markings
Horse's Sex
Mare
Gelding
Stallion
Horse Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your horse insured?
Yes
No
Please Provide Insurance Company Name, Phone Number, Policy Number
If it is determined by the attending PCEVS veterinarian that your equine(s) require referral to/hospitalization at Oregon State University is that an option for listed equine?
Yes
No
If it is determined that colic surgery is needed to save the life of the listed equines (either by initial exam from the PCEVS veterinarian or by Oregon State) is that an option for the listed equine?
Yes
No
I, the owner of the above listed equine, give my permission to the veterinarians at Pacific Crest Equine Veterinary Services to perform emergency services on the above named equine(s) in my absence. If the emergency if life threatening, the doctors may use their best judgment in determining if my equine can be saved within a reasonable medical probability and financial practicality with a cost cap designated below. I will pay for all services rendered up to this cost cap at the time of service. I authorize Pacific Crest Equine Veterinary Services to charge my credit card up to the financial limit designated below.
Financial Limit for Services Rendered by PCEVS
If the veterinarians at Pacific Crest Equine Veterinary Services determine that my equine(s) cannot be saved due to the severity of the condition and/or financial constraints, I, the owner of the above listed equine(s) hereby authorize Pacific Crest Equine Veterinary Services to euthanize my equine for humane reasons.
Yes
No
Please call the office to provide a credit card to use in the event our services are needed for an emergency. (503) 632-6336
**Arranging hauling is the responsibility of the owner and/or authorized representative listed on this form. PCEVS DOES NOT have capacity to transport/haul your equine **The cost of colic surgery or any medical treatment performed at Oregon State is payable directly to them and is IN ADDITION to the costs payable to PCEVS for emergency care.
Special Instructions or Requests
I, the owner of the above listed equine(s) have read this form fully and understand that if I cannot be reached and my horse has an emergency, the veterinarian at PCEVS will proceed with decisions authorized on this form.
Signature
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