Permission to Provide Services
Pacific Crest Equine Veterinary Services
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Horse's Name
Horse's Age
Horse's Color
Horse's Sex
Mare
Gelding
Stallion
Is your horse insured?
Yes
No
Please Provide Insurance Company Name, Phone Number, Policy Number
If your horse were to require colic surgery, is that an option?
Yes
No
If your horse were to require referral/hospitalization (referrals to Oregon State) is that an option?
Yes
No
Is there a financial limit you are willing to spend for treatment?
Yes
No
If there is a financial limit, what is it?
Do you give our doctors permission to make decisions regarding euthanasia?
Yes
No
Special Instructions or Requests
Name(s) of people authorized to make treatment decisions
Please call the office to provide a credit card to use in the event our services are needed for an emergency. (503) 632-6336
Signature
Continue
Continue
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