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Friday, November 21, 2008
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Authorization and Consent for Treatment Form
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| • Horse Name |
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| Type |
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Breed |
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| Color |
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Age |
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| • Owner Name |
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| ID Number |
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| • Street Address |
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| • City |
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| • State |
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| • Zip Code |
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| • Daytime Phone Number |
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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): |
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| Reason For Appointment |
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| Date of Appointment |
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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 desirabe 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 Merritt & Associates to ride the above described horse. I hereby authorize and consent to such a ride and I agree to release, indemnify and hold Merritt & Associates, 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 Merritt & Associates riding the above described horse.
WARNING: UNDER THE ILLINOIS 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 upon discharge of my horse. Should I fail to comply with this policy, Merritt & Associates is authorized to charge my credit card for the entire balance. I realize that my account is subject to an interest charge of 1.75% per day on any balance over 15 days and that I am responsible for all collection costs if this invoice is not paid pursuant to its terms and conditions. |
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| • Credit Card Type |
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| ** Full Name On Card |
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| • Expiration Date |
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| • Credit Card Number |
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VISA - All Visa Credit Card Numbers must contain 16 digits. Please do not use spaces, tabs, or dashes when entering your Credit Card Number. |
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MASTERCARD - All Mastercard Credit Card Numbers must contain 16 digits. Please do not use spaces, tabs, or dashes when entering your Credit Card Number. |
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AMERICAN EXPRESS - All American Express Credit Card Numbers must contain 15 digits. Please do not use spaces, tabs, or dashes when entering your Credit Card Number. |
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DISCOVER CARD - All Discover Card Credit Card Numbers must contain 16 digits. Please do not use spaces, tabs, or dashes when entering your Credit Card Number. |
| • ** CCV Number |
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** VISA CCV - All Visa CCV Numbers contain 3 digits. The CCV number appears on the reverse side of your credit card (where your signature appears). |
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** MASTERCARD CCV - All Mastercard CCV Numbers contain 3 digits. The CCV number appears on the reverse side of your credit card (where your signature appears). |
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** AMERICAN EXPRESS CCV - All American Express CCV Numbers contain 4 digits. The CCV number appears on the reverse side of your credit card (where your signature appears). |
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** DISCOVER CARD CCV - All Discover Card CCV Numbers contain 3 digits. The CCV number appears on the reverse side of your credit card (where your signature appears). |
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