Hospital Admission, Consent & Agree to Pay HOSPITAL ADMISSION, CONSENT, & AGREE TO PAY Admission / Appointment Date Month Day Year Owner / Agent InformationName First Last PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Equine InformationPatient Name Breed Color Age Sex Male Female Reason for Admission Feeding InfoHay Type Supplements Special Needs of Equine Patient Consent SectionConsent(Required) I Agree(Required)I am the owner or agent for the owner of the animal described above and have the authority to execute this consent.Consent(Required) I Agree(Required)I hereby consent and authorize the veterinarians and staff of McKinlay & Peters Equine Hospital to perform the above procedure(s).Consent(Required) I Agree(Required)I have been advised regarding the nature of the procedure(s) and the risks involved, these have been explained to me and are understood by me, and I understand that results cannot be guaranteed nor assurances to results which may be achieved. I have addressed any questions or concerns I may have regarding the procedure(s).Consent I Agree I have discussed the probable consequences of not providing the animal with certain medical or surgical treatment, and do not wish the following treatment or procedures to be performed:List Procedures to not be Performed: Consent(Required) I Agree(Required)I understand that the support staff of McKinlay & Peters Equine Hospital will be employed as deemed necessary by the veterinarian to assist in the treatment of the above-named animal. I hereby release the veterinarians and staff of McKinlay & Peters Equine Hospital. I understand that unforeseen conditions may be revealed during the performance of the procedure(s) and that extended or different procedures may be necessary in addition to the procedure(s) named above. Therefore, I hereby consent to and authorize the performance of such procedures(s) that may be deemed necessary by the veterinarians of McKinlay & Peters Equine Hospital in the exercise of their professional judgement for these procedures and any unexpected lifesaving emergency care deemed necessary by the attending veterinarian. I release the veterinarian and staff of McKinlay & Peters Equine Hospital from any and all liability associated with performance of any additional procedure(s) that may be required.Consent(Required) I Agree(Required)I also authorize the use of appropriate anesthetics and other medications. I understand that there are risks associated with the use of any drug or anesthetics, and 1 release the veterinarians and staff of McKinlay & Peters Equine Hospital from any and all liability associated with the use of anesthetics or other medications.Consent(Required) I Agree(Required)I understand that all horses admitted to McKinlay & Peters Equine Hospital must be current on required vaccinations. If the horse is insured, it will be the responsibility of the owner to inform the insurance company of the procedure(s) and have them contact McKinlay & Peters Equine Hospital for further details.Insurance Company PhoneConsent(Required) I Agree(Required)I understand that any estimates provided to me may not be exact and that other expenses may be incurred in the course of treatment. As owner or agent, I agree to be responsible for payment of any and all charges associated the treatment of the above named animal. It is the owner or agent's obligation to inquire about all costs of patient care and to maintain knowledge of the status of the financial obligation to the Hospital.Consent(Required) I Agree(Required)I understand that a deposit is required upon admission. I further agree to pay the full balance due, including boarding fees, before the release of the animal from the hospital.Hospitalized Patient Deposit Policy: $500 Deposit — Reproduction Patient $500 Deposit — Hospitalized Patient $1,000 Deposit — Hospitalized Patient requiring fluid treatment 1/2 of Estimated Surgery Cost or $1000 (the greater of the two) — Surgery PatientsConsent(Required) I Agree(Required)If it is necessary to bring an action to compel the payment of fees or costs, the undersigned shall pay all costs incurred in the collection of the debt and all reasonable attorney fees and service charges as allowed by the state of Washington and Idaho.Method of PaymentPayment Type Check Cash Credit Card Check # A deposit is required. Please call our office with your credit card information at (509) 928-6734Signature(s) SectionWaiver & Release of Liability: I hereby release McKinlay & Peters Equine Hospital, its officers, employees, representatives and agents, from any and all liability, claims, costs, expenses, injuries and/or losses I may sustain regarding the Patient. By signing below, I acknowledge that I both read and understand this Waiver and Release of Liability and accept the risks which may or may not be readily foreseeable, including without limitation personal injury and property damage that arise from the above-referenced procedure(s) or operation(s). I furthermore accept and agree to the payment policy for said Patient.Owner Signature(Required)Owner Signature Date Month Day Year Agent SignatureAgent Signature Date Month Day Year Witness SignatureWitness Signature Date Month Day Year Equine Patient Doctor CAPTCHA Δ