THREE COUNTIES EQUINE HOSPITAL LLP ADMISSION & CONSENT FORMS

Nam e Add ress

Tel num bers Ema il Poin t of Cont act Nam e Tel num bers Pati ent Bree Age d Colo Gen ur der Pas Sect spor ion t No IX sign ed off Micr Wei ochi ght p no Case Vet/ HS Adm itted by Ref Vet THREE COUNTIES EQUINE HOSPITAL LLP ADMISSION & CONSENT FORMS Tel no: Disc harg ed by Fax to Ref Vet Data enter ed on Eclip se

Reason for Admission Date of Admission Date of Discharge Clinical History – does the horse have any relevant clinical history?

I hereby give permission for the administration of treatment or medication for my horse, including products licensed for use in other species or humans where appropriate.

I understand that I will be expected to settle the account on collection of my horse unless prior discussions have taken place with Three Counties Equine Hospital LLP

If relevant:

I hereby give permission for the administration of an anaesthetic to the above animal and for the surgical operation detailed on this form, together with any other procedures which may prove necessary. I understand that all anaesthetic techniques and surgical procedures involve some risk to the animal.

Signed:...... (Owner/Agent) Date: The signatory must be over 18 years of age.

Name: ……………………………………..(Block Capitals) THREE COUNTIES EQUINE HOSPITAL LLP ADMISSION & CONSENT FORMS

Owne Patient r

Has the horse been vaccinated in the last 24 Yes/No Date of Vaccine months for tetanus toxoid? Does the horse have any known drug allergies? (please specify) Has the horse’s passport been seen Yes/No Date Seen Is the horse stabled or grass kept? Is the horse bedded on straw or shavings? Is the horse rugged or not rugged? Is the horse fed hay or haylage? Date of last wormer? Has the horse been outside the UK in the last 6 Yes/No weeks Diet Type of Feed/Supplements How many feeds per day? Quantity given Equipment left Equipment Left: Yes/No Date Returned to Owner Passport Rugs Headcollar & Rope

Insurance Details Is your horse insured? Yes Will you be making a claim Yes / No Has the insurance company been Yes / No Is this claim New / Continuation? notified Insurance Company NFU Insurance Excess Policy Number Claim Number Type of Cover Mortality Yes / No Sum Insured £ Loss of Use Yes / No Sum Insured £ Veterinary Fees Yes / No Sum Insured £

Estimate of Costs £ Estimate Given by Prepayment/Deposit amount (cash/card) Payment Terms Invoice This estimate does not constitute a final invoice and costs may vary should further diagnostic or therapeutic procedures become necessary. I understand that by signing this estimate I accept responsibility for the bill. In the event of an emergency hospitalisation, I will provide insurance details (if applicable) within 24 hours of admittance.

Signed:...... (Owner/Agent) (The signatory must be over 18 years of age).

Name: ……………………………………..(Block Capitals) Date: THREE COUNTIES EQUINE HOSPITAL LLP ADMISSION & CONSENT FORMS